Chapters Transcript Video Coding — Best practices to take home today - William Cobb, M.D. All right, we'll move on. Um, doctor Cop is gonna do a little bit of coding for us. All right. So my last presentation here is I would make this really short, actually, because I just gave my slides, too. The fellow in the back, I think, is going to make available to all of you. And so most of this is for your reference sake, anyway, and me sitting here and boring you to death with how to code, you know? And this is one of those we talks like Todd mentions. E not me. This was my coder that put this together for me. So, um, but this will give you some tips. There was a good question over there about the diced Asus reinforcement and stuff like that. Um, so you'll have all of this. So, um, don't sit down and have to feel like you frantically write this down. I just want to thank Oregon. This is my last talk getting us together, eating some sushi with Hannaford and, uh, Fisher last night and drinking some bourbon. Uh, anyway, and good to see everybody here at the holidays. So if you have a wonderful holidays with your family. And, uh, it's just good to get out and see folks again. And hopefully this will stay up because omicron will go away or, you know, whatever the next one is will survive as well. So just good to see everybody. Um, so for coding, you know, obviously just basic principles. You know, you have to document the age of the patient. Of course, particularly practice if you're doing kids when it comes to England, Wales, Um, you know what's important now, of course, is that the presence of gangrene and then whether or not it's, uh, incarcerated. So this is the sort of the big ones from eventual hernia standpoint. Of course, in the building of the procedure that the procedure approach, whether it's open, lap or robotic, is important, um, and then the with or without mesh placement. Of course, the vast majority of the time you're going to be using mesh. Um, and then you know the lap codes it's built in so you can't add on. Whereas with the open approaches, the the mesh is A is an add on code that actually does not get reduced. Uh, in your list of procedures this is just in South Carolina. This is what Medicare allows. And so I put the allowable as well as the work our view associated for South Carolina. Of course, it'll be a little bit different in your state, but you can see, um, you know, just get a sense for in terms of severity, but But also, you know, the increases that are, um, present when you start, uh, noting that they're incarcerated or that their recurrent or, you know, incarcerated or strangulated things like that starts to go up pretty dramatically. So don't Don't forget those things, which can be important. Um, all of these, of course, are bilateral codes. If you do both sides and you can build an assist for all of these as well for laparoscopic ventral, um, interestingly, you can also build it bilaterally. And so that means if you have to separate, uh, locations for hernias that are far enough apart, you're placing two separate pieces of mesh. You could, in essence, bila bilateral procedure. In that scenario, if you had an upper gastric and you know an umbilical and you didn't want to extend one massive piece of mesh and you put two smaller pieces. You could code that as a bilateral procedure, these have assist codes or ability to put an assist as well. And again, mesh is rolled up into all of these charges already for open ventral. When you start to get into some of the more complicated procedures and and muscle flaps and things like that, now we'll touch briefly on these and so again, open. Important. You're gonna see a little bit of a reduction just because you will be able to add the mesh implantation, which will give you a little bit more money as well to catch it up more in the range of the laproscopic repairs. But you can just see the differences if it's a Primary. If it's recurrent incarcerated, strangulated all that good stuff. Um, there's the mesh code as I mentioned $255, um And if you are views attached to it as well, and that is not reduced, and so normally, of course, you know your builders will put your highest code first. Then we'll go 50. Gosh, what? I think it depends upon your payer, but usually they'll reduce 50, I think for the first or for the next three or four codes, and then it goes to 25 and then zip after the fifth. But that implantation code of mesh is not reduced to 55 if you use mesh for the procedure. And it doesn't matter what type of mess that synthetic that's By absorbing. That's biologic the biologic companies for a while, or telling folks to use the 15,000 codes for the tissue implants. And, uh, college of surgery came out and said, Please don't do that because that's illegal, Um, for the different adjuncts, if you will. So this is where you really start to get some, uh, reasonable compensation for your effort. Um, so the 15 734 that's gonna be your workhorse. That's gonna be your component separation. Um, now, like Chase said earlier, you can code for and try to get paid for whatever you want. I'm a Georgia guy, which you got a big game day. I like to wear red. You know, Todd's a Clemson dude, so he's used to being in orange. And so if you're comfortable in orange, maybe you want to push the limit a little bit more. But you know, I want to. I want to stay out of jail. So, uh, but, you know, there's been a lot of controversy, you know? Do you just consider a sto puh? Um, my fashion flap advancement. I can listen to both sides of the argument, but remember, this all gets back to the time and the work that was put into it. Um, for a while there, initially, my partners were coding four components separations. They were doing the retro mod gives Fisher heartburn doing the bilateral my, uh, retro muscular dissection. And then if they added a tar or Ramirez, two more releases, Um, please don't do that. And so claim it. Whatever it means in your practice, if you think a retro muscular dissection, you could certainly, um, justify that. That being a Maya fashion flap, Um, I personally don't do that, but But again, you gotta put your head on the pillow at night. So But you can see there. The RVs that are attached to it are not insignificant. The global attached. It's not a bilateral codes. If you do it on both sides, we'll talk about here. In a second, you're gonna have to use a modifier as a distinct procedure. And so it will get reduced 50% for the second side. But you don't build as a bilateral. It's not the 50 modifier. Um, assists are all good for this. Some of the other crazy stuff we do. If you're doing create new mo, uh, to prepare folks and you put intra peritoneal catheters in, um, you obviously bring that patient in a week prior and you can put those catheters even lap or open. And then every time you inject air in their belly, get a little bit of money for doing that. And so that does not get, um, you know, as long as you define it and put in your operative note that it's a progressive therapy, then you will get the full freight each day that you blow that patient up at the bedside, taking the catheter out for the repair. You'll add that, and then when you start doing your particular economies, which I'm sure fish has a lot more experience getting these paid for. I think that in our experience, it's like, yeah, nice try. We put this, but we never get comped for it. But you can try and Todd uses some of the There's 1100 codes when you mobilize skin flaps and things like that so you can add some of the tissue dissection of the skin removal, Uh, as well. It just depends upon your pears or whether or not they're gonna get you're gonna get any compensation that CMS I can tell you you're not, um so for the mesh placement again, it's the the add on code that's not reduced, Um, and the independent of what type of mesh. So stay away from you know, the mesh biologic companies trying to tell you to use the, Um, the zen a graph on the skin substitute a section that's meant for burn patients and stuff like that. And don't use that for your hernia repairs. Just some of the modifiers of the 22 modifier that is an important one to use, particularly with the laproscopic repairs. Um, I don't really see situations where you would use it for opens because, you know, if it's a difficult recurrent, the fact that you put a recurrent, they're they're kind of baking in some of the fact that that's going to be a more difficult repair uh, we use it more for extensive life's of adhesions if we're doing a intraperitoneal repair, Um, I guess theoretically, you could add it on for the open as well. Don't use the separate lights of adhesions code. They'll kick that out right away. Use the 22 modifier and document in your note. How much additional time it took you? Usually the triggers an hour. If you say it took you more than an hour to do the procedure from just the easy license standpoint, then that will usually, uh, trigger that to potentially get paid. Um, the distinct procedural service. So again, if you're going to use, um, The, uh the 15734 and you're going to do it on both sides, you're gonna do a 59 modifier so that you won't use the 50 is the bilateral because it's not a bilateral code, but you'll do. The 59 is a distinct, uh, same procedure in a separate location, distinct from the first one, and that that will get you comped for that. Um, just some other you know, obviously you take patients back, and this is just coding in general. Assistant surgeon fee they do get about 16%, at least in South Carolina. I'm not sure where it is with you guys, but for some of these cases, if you're having your plastic surgeon, come in just to provide entertainment, tell jokes, whatever that you can get some assistant fees for these big, complicated cases. If you're a teaching institution, of course, you'll have to document the need for not having a qualified residents. Some would argue that none of them are qualified, but you need to document that it's a very complex case and that you needed, um, your partner to help again. Using some of the 22 modifiers life of adhesions is the big one. But if I'm mobilizing the bladder for the, um, Super pubic, if we're doing, um, laparoscopically, if it's anything that adds additional complexity to the case, document the additional amount of time it took you to do, um and then you can attempt to get the 22 modifier added on now for robotics. This has kind of opened up a whole another new Pandora's box. My guys came to me Oh gosh, about a year and a half ago, looking to put my head on a stick because they started to realize that they were using unlisted codes, uh, for these robotic procedures and they were not getting RV. You credit? And so if you're in an employed model, where are our view is King? Um they will find this out pretty quickly and appropriately. So because they're not getting any credit for these procedures, there is an s code that you can use and some pears will recognize. Medicare is not one of those, Um, but, uh, you know, you might get a little bit from a third party, potentially for those, But for the most part, you're building these laproscopic repairs and your, um you know, just noting that their robotic, um, at the same time, but you're gonna basically get a robot. Um, I'm sorry, laproscopic fee for it. Um, that starts to really get complex. However, when you're doing, uh, steps and tars and things where you're mobilizing flaps which we'll get into here in a second. So just some examples I provided for you guys in just a straightforward or current decisional with component separation and placement of mesh. So again, the Maya fashion flap Advancement code 15 734. You use the 59 modifier on that that will reduce it in half. You put the mesh code the 568, which again does not get reduced because it's, uh, it's the implantation of mesh. And then you'll have the repair of the incision, a hernia as well. And so you did it all, Uh, this same procedure done that same settings. So that's why I use the 51. So essentially all in in South Carolina is a little less than $2,800 is what we get reimbursed for, and these are CMS rates. Um, the documentation needs to be thorough. You guys can copy paste this stick in your epic notes or Cerner whatever E. H. R. That you have, but you need to take the time to identify what you're doing. Um, you know the way I look at it, if you're you know, it's not an insignificant amount of money you're getting for putting the 15 734, so you can't just say I did it. Ramirez released on both sides and expect to get paid. It's not going to happen. You need to document. I like to use measurements, uh, and put the length of the flap, um, cranial caught at and basically just take the length of my the length of my mesh. And that's obviously the extent of the dissection. How far you took it out laterally. How much you feel like you brought the rectus toward the midline. I mean, these are all estimations, but at least gives the It makes it sound like what you did was super complicated. Um And so anyway, I have all these in templates, which is a lot of this. You also want to document that you preserve the neurovascular bundle, and it's nice if you identify what that was in fear of a gastric or identified not, uh, provide, um, blood supply to the flap so all those things will help you get reimbursed. A lot of players are just kicking these things out now, automatically. And so your coders are gonna be wrestling with the company's anyway to get, uh, your your money. So just have good documentation. This is just a lap incision, all with extensive life's of adhesions. And so you document the time. Um, you can use that 22 modifier and get up to 25% depending upon your pair. Um, and again just to comment in the operative report How how difficult it was. Small bowel is involved. You had to carefully take small bowel down. Yes, sir. License Don't do that. That automatically gets tossed. And so you only hope of you getting additional comp for that is to go through the 22. If you if you put the additional. That's a great question, todd. If you go through the likes of adhesions, they will automatically toss that because that's supposed to be built into the repair. Um, this is a you know, pre op Numa where you bring them in, put the catheter and then successively blowing up with air and then take them at day seven to do the, uh, incision or hernia repair. So again, you will get each day that a meager amount of money you get for instilling air, but it doesn't get reduced or kicked out because it's a progressive therapy. And so you need to state that in your pre op in the in the operative portion that it was This is a progressive therapy that's going to be done on successive days. And that's how you'll get something that complicated, coded and paid for. Um, let's see here there was a robot example. Yeah, so for the e tab And again, this is where my guys got really upset Because, um, essentially what you're doing is using all these unlisted laproscopic codes, which I think I just mentioned a second ago. Um, the problem is, there's no RV use attached to any of this because all unlisted for code allows the the coders to do is say, Well, this procedure is comparable to a 15 734 times two. So they try to give that information to the payers, hoping that they'll compensate something close to that. They had done that open procedure, but there's no RV use attached to it. So again, if you're in that type of a model, you're getting screwed if you're doing this. But we had figure out and sort of give them credit for these procedures because they were doing an awful lot of them for because it's not. Yeah, yeah, it's a compare. You're not coding for it's not. You mean you're not doing that dissection and mobilize and flapping all you're just putting it as a comparison. You're putting the unlisted laparoscope on? Yes. Yeah. Okay. See? Mhm. So it's crazy. It's like, right. It was Yeah. What? There's flap. Flap? Yeah. Relate them robotic like, Wow. No. Yeah, they lost so much. The urologists are running into this now, too, because they're doing simple prostatectomy is for the smaller masses. And there's not a simple prostatectomy robot code. It's the radical where you do the node dissection. And so they're having to put in an unlisted laparoscopic urologic code. Compare it to an open, simple prostatectomy. They're not getting RV. You credit. So, um, so be prepared. Work a lot with your coding team. Uh, we meet with them quarterly. Kind of go over the cases that we've built. Um, if we've done a good job, if we've documented appropriately and then from our standpoint, we want them to tell us what we're getting paid. Um, And if we are getting paid, there was a while where United started kicking out everyone of our kids every time we put 15, 734. So we just had to be prepared to send that documentation because they love to play these games and not not pay you guys, um, documentation is key. Um, you know, obviously the level of complexity. And as you start doing these flaps and mobilizing these things, if you just have a you know, another two lines in your operative note explaining all that that's not gonna cut it. So take the time to explain what you did. If you're on a electronic record, it'll make it a lot a lot easier. Um, again, you'll have these slides, please use them. Reach out to me. If you want to Numbers specific to your state. I can certainly have my code or pull those if you care. But hopefully this helps you guys. Thanks. Mhm. Take yeah to place a little too simple. So repair the same billing, Right? Correct. It's not tar, but retrospectives. And four. Yes, right. The ventral hernia repair. Correct. Yes. Yes, yes. Really? There's gotta be a way. Yeah, Bill, for Mr There's something pretty I know you're like, totally into this. But there was a pretty good article that, um, the guys that they s q c just put out about it was guidelines, and it's trying to link it more to time of complexity is what you're saying, but but I'll let John's like the guy. So, like, I heard a rumor, though, that being around her knee is going to change it late inside. I've heard that it's right. The only guys, if North it was right. My attorneys just said they're doing Yes. Yes. And that brings up the fight. Yes. Yes, sir. Just calm with my for my Yeah, that in terms of incarcerated versus reducing long time, all incarcerated fact and then comes into the problem Where what diagnosis could you? They won't pay four nights Before the 4965. You also feel I'm back either obstruct or gangrenous. They presume that the incarceration is about Therefore, there is absence of obstruction for gangrene, incompatible with incarcerate. Look at the diagnosis. Code obstruction can mean that already obstruct something. It doesn't have a rebound. Incarcerated in criminal acts, literal diagnosis some strong right. The opening of the journalism structure so you can use that diagnosis. Wait. What is this? So lost for us Colors, right? No bringing break whether it's what what for? Bird? Yes. Work out. What insurance? Working message. Whether they sure actually really help there. Yeah. Yeah, That's you, Fish. Everybody wants to talk to you, buddy. All right. Thank you all again. All right. Thanks. Dr Cop. Yeah. Published December 15, 2021 Created by
