PCS: It’s time to talk with your surgeons

by Michelle A. Leppert, CPC

Many surgeons use templated notes for their common procedures. Find out what information is not included in the template and work with the surgeons and your IT department to update the template to capture all of the information you need for a PCS code.

 

Ask them to explain what they’re doing. Ask what they mean by certain terms. Many of them will be happy to share their expertise.

 

Find out what usual practice is and develop some facility-specific coding guidelines around them. For example, if your surgeons perform a lot of cardiac artery bypass graft (CABG) procedures, find out which vein they typically harvest—greater or lesser saphenous, right or left.

 

Coders need that information to report a code for the harvest procedure (yes, we get to code that separately in PCS.) The surgeon may just dictate “harvest of saphenous vein.” We can’t code that. We need more information. Instead of querying the surgeon, you can create a default for your facility. See Coding Clinic, Third Quarter 2014, p. 8 for more specifics.

 

If your surgeons routinely use devices as ICD-10-PCS defines them (things that remain after the procedure is completed), they are probably documenting a brand name and a model. That could be a problem.

 

For example, a surgeon performs a hip replacement and documents the device as Stryker ADM X3. When you get to ICD-10-PCS table 0RS, you find these choices for a device:

Which one is the ADM X3? You could Google it or visit the Stryker website. Or you could be proactive and find out before ICD-10 implementation what devices your surgeons use and create a cheat sheet to match the brands to the appropriate device character.

 

One caveat: devices change all of the time, so don’t create a list and forget to update it. Someone needs to keep an eye on what new devices your surgeons are using. Make that someone’s job. Don’t just assume someone else will do it.

 

That brings us to the final point for today—surgical queries. No one really wants to deal with surgical queries. We don’t want to send them and the surgeons don’t want to get them. Until ICD-10-PCS adds an unspecified character choice, we’re stuck with queries.

 

How do we get queries in front of the surgeons? It depends on the surgeon. So you need to invest some time getting to know your surgical staff. Keep in mind, they have approximately a 17-second attention span (according to former ACDIS Advisory Board member Timothy Brundage, MS, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida).

 

You need to be quick, concise, and polite. Ask them how they would like to receive queries. Make a list for all of the CDI specialists and coders, then use the surgeon’s preferred method of communication when you need to send a query. You’ll stay on the surgeon’s good side and probably get a quicker answer.