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Operative note dictation: Tips for knee procedures

By Mary LeGrand, RN, MA, CCS-P, CPC

Although dictation of operative notes might seem straightforward, many surgeons fail to include enough information to enable proper coding of knee procedures not related to joint reconstruction. For example, documentation differentiating open and arthroscopic procedures is often missing; incorrect or nonspecific diagnosis codes may be used; and CPT, G codes, and modifiers may be used incorrectly.

Operative note coding tips
The following tips will help surgeons dictate a clear operative note.

  • Use CPT terminology and include the operative approach in specifying the procedure title. For example, specify “arthroscopic medial meniscectomy” or “open medial meniscectomy.”
  • State whether the procedure is an initial, revision, or staged procedure in both the title of the operative procedure(s) and in the indications for surgery paragraph. The indications for surgery paragraph should also state whether the surgery was performed in the global period of another procedure.
  • State the specific compartment where the surgical procedure was performed. For example, you might specify “medial meniscectomy,” “lateral meniscectomy,” “lateral meniscal repair,” or “medial meniscal repair.”
  • Include in the dictation the specific coding requirements to support reporting procedures as defined by the CPT rules. For example, specific coding rules are related to reporting the arthroscopic removal of loose or foreign bodies in addition to other arthroscopic knee procedures. When appropriate and accurate, dictate that the arthroscopic removal was performed through a separate incision or that the size of the loose or foreign body was 5 mm or greater. Although this may seem trivial, it is the difference between being able to report CPT code 29874 or not, because loose or foreign bodies less than 5 mm or extracted through arthroscopic incisions or via cannulas are not reportable.
  • Specify the compartments where you performed chondroplasty or abrasion arthroplasty. Chondroplasty and/or abrasion arthroplasty performed in the same compartment as a meniscectomy or meniscal repair surgery is included in the CPT code for the meniscal surgery. For proper payment, including the location(s) of the chondroplasty in your dictation is critical if you are reporting this procedure in addition to other arthroscopic knee procedures.

Dictate all procedures performed—even though they may not be separately reportable to the payor. For example, the reconstruction of a dislocating patella—described by CPT code 27422 “Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)”—includes a chondroplasty and lateral retinacular release. Although the chondroplasty and the lateral retinacular release are not separately reportable, they should be dictated in the procedure title.

Once you’ve performed and documented the procedures, use Code-X to determine whether they are considered integral to the primary procedure or are separately reportable (assuming all other requirements are met).

For example, Figure 1 is a screenshot of the 2010 CodeX for CPT code 29881. As shown, services 12–14 are specific inclusions to CPT code 29881, but services 3–6 under the header “Intraoperative services not included in the global service package” are separately reportable when performed, the rules are met, and services are documented.

Diagnosis(es) note dictation tips

  • Dictate both a preoperative and a postoperative diagnosis. Include any additional pathology found intraoperatively in the postoperative diagnosis(es). You can also be more specific, based on your intraoperative findings.
  • Dictate additional diagnosis(es) to support the medical necessity of additional procedures based on intraoperative findings.
  • Dictate to the highest level of diagnostic specificity. Document sprains as current, old, or degenerative and state the specific location as appropriate. For example, ICD-9-CM code 836.0, “Tear of medial cartilage or meniscus of knee, current,” represents a current injury while diagnosis code 717.2, “Derangement of posterior horn of medial meniscus” should be used for an “older” injury. Use CodeX to accurately select and link the correct diagnosis code (Figure 2).

Linking the correct diagnosis to the correct CPT code will help minimize the risk of a claim’s rejection or denial. The claim submission shown in Figure 3 is a fairly common error in orthopaedics and occurs when the surgeon allows a staff person not trained in CPT coding to link the diagnosis to the code.

Note that all three diagnosis codes (717.0, 717.43, and 717.7) were linked to the medial and lateral meniscectomy code (29880) and that the meniscal diagnoses codes were linked to the chondroplasty. Modifier 59 was not linked to the chondroplasty to indicate a separate compartment. As a result, CPT code 29877 was denied for medical necessity and also denied as bundled.

Linking a specific diagnosis(es) to each procedural code is critical. Do not link multiple or all diagnoses to each procedural code unless each diagnosis is appropriate and supports the medical necessity for that specific procedure. Consider reporting concomitant comorbidities, if they affect the physician work associate with the pre-, intra- or postoperative portions of the global surgical package.

The surgeon’s role
The primary surgeon (surgeon of record) dictates the operative note. He or she should dictate the role, medical necessity, and work performed by an assistant (if one is involved in the surgery). If an assistant surgeon (MD or DO) or an assistant at surgery (PA, NP, or CNS) is used, the primary surgeon is responsible for justifying the presence of the assistant, the medical necessity requiring the assistant’s presence, and the work performed.

An assistant, who is billing for his or her services, does not dictate an operative note. If the primary surgeon does not include the information in the operative note, there is no basis to report the assistant’s service. If the bill is denied, the assistant has no documentation to support an appeal.

Procedure details or description
Ensure that the procedures performed are dictated in full in the body of the operative note.

If an abrasion arthroplasty is performed, for example, the actual procedure, where it was performed, and the details of the procedure should be included. This is critical to differentiate billing for CPT code 29879, “Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture,” and CPT code 29877, “Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty).”

The work associated with meniscal repairs, meniscectomies, arthroscopic repairs of anterior cruciate ligament tears, open repairs of multiple ligaments and posterolateral corner tears should be described in detail. Define the specific ligaments and differentiate between a repair and a reconstruction of the ligaments. The codes are different and reimbursement will be affected if the details of the operative note are not specific.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc. The information in this article has been reviewed for accuracy by the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org

Editor’s note: This is the first of a two-part article on coding for non-joint replacement–reconstructive knee procedures. The second article will address knee coding scenarios to highlight the accurate use of modifiers and the correct coding of procedures for chondroplasty and removal of loose bodies.

AAOS Now
April 2010 Issue
http://www.aaos.org/news/aaosnow/apr10/managing1.asp