By the Surgical Notes Coding Department
Coding mistakes can cause a number of problems for ambulatory surgery centers.
They lead to increases in denials and wasted time and resources. Downcoding
errors can cause ASCs to leave money on the table while upcoding errors
can trigger fraud investigations if there is suspicion of intentional
To help your ASC reduce coding errors in 2023, follow these tips.
1. Understand the modifiers for canceled procedures. If a procedure is canceled in the operating or procedure room before it's
started, coders should code the planned procedure with the appropriate
modifier to indicate the anesthesia status. Use modifier -73 for procedures
discontinued prior to the administration of anesthesia. Use modifier -74
for procedures discontinued after the administration of anesthesia.
If multiple procedures are planned but none are performed, only the primary
procedure is reported with the appropriate modifier. If one procedure
is completed and a second is started but not completed, code the first
procedure with no modifier and report the second procedure with modifier
-74. Any additional planned procedures not started are not reported.
2. Avoid unspecified HCPCS implant codes. Before submitting a claim to a carrier, or when working an appeal, always
review your implant HCPCS code. If a generic code was used (e.g., L8699),
check to see whether a more specific code can be used. Ensure you follow
the payer's specific requirements.
3. Code arthroscopic rotator cuff repairs identically. Whether a rotator cuff tear is acute or chronic, arthroscopic rotator
cuff repairs are always reported identically using CPT 29827 (Arthroscopy,
shoulder, surgical; with rotator cuff repair).
4. Code open rotator cuff repairs differently. Open rotator cuff repairs require documentation to indicate whether the
tear is acute or chronic. Use CPT 23410 for acute repairs. Use CPT 23412
for chronic repairs.
5. Closely review the operative report when coding esophageal dilations. Proper coding of esophageal dilations requires coders to understand the
type of dilation performed. There are many CPT choices for coding esophageal
dilations, including CPT 43248 (Esophagogastroduodenoscopy (EGD) with
insertion of guidewire followed by passage of dilator through esophagus
over guide wire); CPT 43450 (Dilation of esophagus by unguided sound or
bougie (may or may not be done in the same setting as an EGD, which is
separately reportable); and CPT 43453 (Dilation of esophagus over guide wire).
6. Understand the expanded endometriosis codes. For fiscal year 2023, all endometriosis codes were expanded to include
several more specific locations and the depth of the lesion(s). To ensure
the correct and most specific code is used, look up the diagnosis in the
ICD-10-CM index and then review the code selection in the tabular.
7. Remember to use the subchondroplasty code. In 2022, subchondroplasty procedures were assigned their own CPT code
(they were previously unlisted). That CPT code is 0707T (Injection(s),
bone-substitute material (eg, calcium phosphate) into subchondral bone
defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular
fracture), including imaging guidance and arthroscopic assistance for
8. Use the new drug-induced sleep endoscopies code. For drug-induced sleep endoscopies, don't forget to use CPT 42975 (Drug-induced
sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base,
and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic).
This code was introduced in 2022.
9. Choose the correct eustachian balloon dilation code. There are two codes for eustachian balloon dilations. The difference: one
is for unilateral procedures; the other is for bilateral. These codes
are as follows:
- 69705 — Nasopharyngoscopy, surgical, with dilation of eustachian
tube (ie, balloon dilation); unilateral
- 69706 — Nasopharyngoscopy, surgical, with dilation of eustachian
tube (ie, balloon dilation); bilateral
10. Avoid eponyms. Better documentation in an operative report translates to faster —
and, more importantly — more accurate coding. That's why it's
advisable to always document the details of procedures and all anatomy
involved instead of just naming the procedure. For example, rather than
documenting, "I then performed a Mumford procedure," detail
the amount of distal clavicle removed in centimeters or millimeters and
include the method(s) of removal. As another example, for Austin/Akin
bunionectomies, document the location of any osteotomies.
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