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AAP Survey Overview. William J. Cromie, MD FAAP. Observations. In the future, provide full operative notes. What is unstated creates problems for coders. Conservative versus aggressive coding. Chose two or more codes when one code adequately described service performed.

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aap survey overview

AAP Survey Overview

William J. Cromie, MD FAAP

observations
Observations
  • In the future, provide full operative notes. What is unstated creates problems for coders.
  • Conservative versus aggressive coding. Chose two or more codes when one code adequately described service performed.
  • Modifier 22 appeared inappropriate for cases submitted. However, included in 10% of responses.
observations continued
Observations Continued
  • National coding guidelines are black and white. Software can only edit the codes submitted.
  • Documentation may be required for support when multiple codes are submitted.
  • Submission of incidental procedures, e.g. CPT code 66425(injection of anesthetic agent) per the CPT Surgical Package Definitionsection,is considered incidental to the procedure and would not be paid separately
case presentation case 3
Case Presentation: Case #3
  • 6 month old male with chordee without hypospadias. Procedure performed: Phalloplasty with rotation of dorsal preputial flaps to cover the ventral penis along with removal of excess prepuce. Corporal body plication performed to correct chordee.
  • 54304: Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps, described all of the elements of the procedure.
  • 54300: Plastic operation of penis for straightening of chordee (e.g., hypospadias), with or without mobilization of urethra.
  • 54360: Plastic operation of penis to correct angulation.
unbundling example case 3
Unbundling Example: Case #3

Survey example- provider submitted five codes:

54300, 14040, 13131, 64430 and 54161

  • 54300 recognized and accepted.
  • Code 64430(Injection) would be considered global.
  • Code 54161(Circumcision)is frequently performed with other hypospadias procedures and would be considered incidental.
  • Neither of the above codes would be paid
  • Codes 14040 and 13131 would require additional medical documentation to support whether a separate repair was needed.
industry standards
Industry Standards
  • Multiple procedure processing
  • Code auditing software
  • Plans found non-compliant or “How Aetna got in trouble”
  • Up-coding and fraud laws “Federal False Claims Act, USC 3729-3733 for medicare and medicaid fraud, or “ How Tenet Healthcare got to pay back $900 million to the federal govt.”
take aways
Take-Aways

Keys to correct coding:

  • Use current updated CPT Manuals
  • Document, Document, Document!
  • Be realistic in coding
  • Use modifiers judiciously:

22-unusual procedure,

59-distinct procedure,

76-repeat by same MD,

77-repeat by another MD,

78-return to OR for related procedure,

79-return to OR for unrelated procedure or service by same MD