Let body of operative report guide code assignment

Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN, CCDS, CPC-A. Coders they should review the complete operative report before coding as increased regulatory compliance and auditor scrutiny make this essential, says Spryszak, CDI education director at HCPro, Inc., in Danvers, MA.

"Waiting for the operative report means coders will have all of the information and can code accurately," she says.

Another important reason for reviewing operative reports is that they may indicate additional procedures that exceed what physicians originally list in progress notes or preoperative consent forms, says Spryszak. For example, a progress note may indicate a patient needs a laparoscopic cholecystectomy. During the procedure, the physician documents addressing significant peritoneal adhesions or providing attention to another organ as well as removing the gallbladder. These may be codable services not listed in the original progress note, she says.

The duration of the procedure-particularly when it's longer than average-sometimes provides a clue that the operative report may have more information, explains Spryszak.

Also, coders and CDI staff need to remember that a preoperative consent may include a list of potential procedures the physician might perform, while the operative report will include more definitive information, she says.

Confirming or clarifying the surgical approach (e.g., laparoscopic or open) is another reason to read operative reports, says Spryszak. "Although the patient consent may include both approaches, coders must refer to the operative report to determine which approach the physician actually used," she explains.

Physicians may sometimes use a certain procedure in the title of an operative report but describe it differently in the body of the report. For example, Coding Clinic, Third Quarter 2010, p. 12, describes a scenario in which a colorectal surgeon titles the operative report "low anterior resection of the colon" (LAR). However, the body of the report documents a procedure during which the physician resects the entire sigmoid colon and a "little bit of the rectum."

Coding Clinic instructs coders to assign ICD-9-CM procedure code 45.76 (open and other sigmoidectomy) for this procedure because the operative report indicates that the surgeon performed a resection of the sigmoid colon-not an LAR. The Coding Clinic reference indicates that an LAR involves resection deep in the lower pelvic region.

However, even the phrase "deep in the lower pelvic region" can be confusing, says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. "[Documentation of an LAR] should reflect that it was a resection of the rectum itself," he says. "An LAR is a rectal resection-usually with a small portion of the sigmoid."

When the title of the operative report is "LAR," review the body of the report and, says Gold, look for the following information:

• Length of specimen. A rectal resection alone has a specimen typically 10 cm long, whereas a sigmoid resection has a specimen usually exceeding 20 cm.
• Microscopic description. When the rectum alone is resected, the longitudinal muscles surround the bowel, whereas with a sigmoid resection, the longitudinal muscles are in three distinct bundles.
• Other operative descriptors. If the operative description states that the surgeon mobilized the splenic flexure to bring the distal end of the left colon down to the pelvis, the physician performed a sigmoid resection.

Query physicians whenever documentation is unclear, vague, or inconsistent. If a physician documents "LAR," query to determine whether he or she performed a resection of the sigmoid colon or the left colon, or a left hemicolectomy including the left colon and sigmoid, says Gold.

Prepare for RAC surgical targets
RACs are examining documentation to ensure that it supports coding focusing on three surgical targets:

•  Excisional debridement
•  Lung biopsies 
• Adhesiolysis

Adhesiolysis is challenging because physicians often perform it as an intrinsic part of the surgery. Coders can separately report the procedure only when it's documented as a barrier to a simple procedure.

Consider these questions when preparing for RACs:

1. Are RACs looking for specific language in operative reports when justifying a service? Use this information to educate coders, CDI specialists, and physicians, says Spryszak.
2. Do any patterns exist with respect to denials, either internally or at other hospitals? Which surgical procedures are targets? Use internal data mining to determine your volume of these targets and random audits to establish whether documentation can withstand an audit.

Highlights from latest issues of Coding Clinic
Be sure to take a look at Coding Clinic, Third and Fourth Quarters 2010, if you haven't already. Highlights from these two issues include:

• When a primary lung cancer metastasizes into another­ lobe of the lung, the second lesion should receive an additional code as a metastasis-not as a primary ­lesion. However, coders cannot assume that a second lesion is a metastasis or a primary cancer of both lungs. If two primary lesions occur in the same lobe, a coder may report only one code. (Third Quarter, p. 3)
• Count the period of ventilator weaning during the process of withdrawing the patient from ventilator support. The duration includes the time the patient is on the ventilator as well as the weaning period. It ends when the mechanical ventilation is turned off (after the weaning period). (Third Quarter, pp. 3-4)
• Report complication code 997.02 (iatrogenic cerebrovascular infarction or hemorrhage) as well as code E934.4 (drugs, medicinal and biological substances causing adverse effects in therapeutic use) in the instance of a patient whose hemorrhagic conversion was caused by tPA therapy. (Third Quarter, p. 5)
• Excisional debridement of the fascia to the bone should be reported with 83.39 (excision of lesion of other soft tissue) and not a code for excisional debridement of the bone. (Third Quarter, p. 11)
• When physicians document "hypertensive urgency," a query is necessary to determine the specific type of hypertension. (Fourth Quarter, p. 9)

Editor's Note: This article first appeared in the March 1 edition of Briefings on Coding Compliance Strategies.