It may be hard to imagine that payers really read the operative notes to make sure the documentation supports the work performed, but the reality is that when services reported don’t match the codes submitted, payers pay attention.
A recent case filed in a United States District Court is just one example. In addition to multiple coding and documentation issues, the federal government identified that CPT codes and charges were inappropriately being submitted for the arthroscopic removal of loose bodies. They found that the documentation either did not support the size of the loose bodies (smaller than required to report the code) or did not indicate that the loose bodies were ever removed.
Seven CPT codes cover the arthroscopic removal of loose or foreign bodies in various joints (Table 1).
Documentation requirements for arthroscopic removal of loose or foreign bodies differ, depending on whether the procedure is performed by itself or in conjunction with another arthroscopic surgical procedure in the affected joint.
If the only procedure performed is the arthroscopic removal of a loose or foreign body, the documentation must show that the actual work was performed and the procedure was supported by medical necessity.
If the arthroscopic removal of loose or foreign bodies is performed in addition to other arthroscopic surgical procedures in the same joint, the following documentation must exist to support reporting the appropriate CPT codes for both the removal of loose or foreign bodies and the other arthroscopic procedures:
- The loose or foreign body (bodies) must be larger than 5 mm in diameter or
- A separate incision was required to remove the loose or foreign body (bodies)
If the patient is a Medicare beneficiary and another arthroscopic procedure is being performed in the knee along with the removal of a loose or foreign body, Medicare requires the loose or foreign body to be in a different compartment than the other arthroscopic procedure, as stated in the definition of the G code.
In the following situations, the arthroscopic removal of loose or foreign bodies is not reportable according to CPT rules:
- Size is not documented as larger than 5 mm.
- Documentation does not state a separate new incision or new portal was created to remove the loose body.
- Multiple loose bodies are “washed out” without documentation of size or separate incision/portal.
- A chondroplasty is performed in the same compartment.
If the rules for reporting are not met, the removal of the loose or foreign body (bodies) is not separately reportable. Payers are paying attention to this issue, and so should you.
Check your documentation
If you’re not sure your documentation is 100 percent “up to snuff,” take the following steps:
- Run a CPT frequency report and determine the frequency of those codes reported as a solitary code (uncommon) and those reported in conjunction with other arthroscopic procedures.
- Audit a sample of charts to ensure the documentation requirements are being met.
- Ensure medical necessity (eg, correct diagnosis is linked to the appropriate CPT code).
- Close any coding or documentation gaps you may find in your documentation.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.