Recently, I hosted a webinar titled “How to Accurately Dissect an Operative Report,” where we had a very fruitful Q&A session after we wrapped up the presentation. Not surprisingly, we weren’t able to answer all of the questions asked by attendees, so I promised to write a blog post to do just that. And here it is. As always, if you have any additional questions, feel free to ask them in the comment section below the post.
We hope you’re staying safe out there!
Question1, from Debra D.:
What if Lysing adhesions take an additional 5 Hours. Would you still only use modifier 22?
Check the CCI edits for your code with the code for the adhesions. If they are bundled then, yes, you can only use the modifier 22.
Question 2, from Rhonda E.:
Do you have a document that states what must be included in an operative report? I know there used to be one, but that was around 2011 AHIMA.
The guidance I used comes from many sources, but you might try the JHACO website: https://www.jointcommission.org/en/
Question 3, from Mark L.:
Does Medicare and other insurance companies have specific timeframes for signing operative and other reports?
No, but in my experience the 72 hour rule is typical.
Question 4, from Mark L.:
What about proper documentation for the assistant in the surgery. Etc.?
The provider should document exactly what the assistant did, and why they were necessary.
Question 5, from Lori N.:
I had a surgery case where the gynecology surgeon called in a urology surgeon to help with the surgery. Each surgeon used CPT code 58662 for two separate body areas. An assistant also helped the gynecology surgeon. Can I still bill for the assistant using that same code 58662 with modifier 80?
Yes, just make sure your provider documents the reason for having a co-surgeon and an assistant.
Question 6, from Bev P.:
Regarding assistants at surgery; we have taken on some complex specialties recently that use MDs and mid-levels to assist. Is it ever appropriate to bill for more than one assistant per CPT procedure? I have told the MDs that their operative report should specify who helped with what, otherwise we can't determine how to bill the assistant(s).
Yes, I have seen cases where there is more than one assist. Just make sure your provider documents the reason and the exact details of who did what.
Question 7, from Abby W.:
When coding for a skin excision, can you use the sizes off of the path if none are documented in the operative report?
Only as a last resort. The lesion shrinks once removed, so the dimensions on the path report will be smaller.