By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Senior Director, Coding
Missing information in an operative report is a common cause of billing
delays. If the documentation needed for coding is missing or unclear,
the coder must initiate a physician query to obtain the information. The
tips below, focusing on the integumentary system, will help reduce the
number of queries required, increase overall compliance, and secure optimal
revenue for your ASC.
Skin biopsies — Document the type of biopsy (tangential, incisional/wedge, punch)
and the number of lesions biopsied.
Skin tag removal — Document the total number of skin tags removed.
Lesion excisions — Document the total size of the excision in centimeters (cm), including margins.
Lesion shaving — Document the specific location and size of each lesion.
Wound repairs — Document the linear dimensions in cm. In addition:
- Include documentation regarding the specific tissue layers repaired. Per
CPT wound repair guidelines, identification of tissues repaired is required
to support intermediate and complex repairs. The tissues repaired must
include deeper tissues (e.g., subcutaneous, fascia, muscle) in addition
to dermis and epidermis.
- Document the extent of undermining tissue to differentiate between intermediate
Debridement — Document the specific layers debrided (skin, subcutaneous, muscle/fascia,
bone) and include the total area of debridement in cm2.
Dermal fillers — Document the amount of the injection in cubic centimeter (cc).
- Include the filler injected for accurate HCPCS reporting/reimbursement.
Adjacent tissue transfer (ATT) or rearrangement — Document the anatomical location and the area in cm2 for each ATT, including primary and secondary defects.
Stay tuned for Part II next month when we share more tips for integumentary