surgical auditing for...

11/6/2013

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Surgical Auditing for OrthopedicsSurgical Auditing for Orthopedics

Presented by

Robin Zink CPCRobin Zink, CPC

Brenda Edwards, CPC, CPB, CPMA, CPC‐I, CEMC

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AgendaAgenda

• Documentation

• Consent

• Auditing

• ICD‐9‐CM to ICD‐10‐CM example• ICD‐9‐CM to ICD‐10‐CM example

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DocumentationDocumentationPurpose• Outlines logic used in treating patient

• Brief history of the problemBrief history of the problem

• Demonstrates why a particular surgery was performed

• Pre‐and post‐operative information

• Consent to treat

f• Basis for reimbursement

• Supports medical necessity

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DocumentationDocumentation

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DISCHARGE STATUS: DISCHARGE STATUS: ALIVE BUT WITHOUT PERMISSIONALIVE BUT WITHOUT PERMISSION

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Elements of Operative noteElements of Operative note

1. Identifiers

2 Procedure Summary2. Procedure Summary

3. Procedure Story

4. Findings

5. Additional Information

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JCAHO Standard IM.6.30JCAHO Standard IM.6.30

• Elements of Performance (EP) 3 details data elements for dictated operative reportp p

• Operative reports (dictated) immediately after a procedure must record– Name of primary surgeon and assistants

– Findings

– Procedure(s) performed

– Description of procedurep p

– Estimated blood loss, as indicated

– Specimens removed

– Post‐operative diagnosis

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• Element of Performance (EP) 4 details authentication requirements


requirements

– Completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure

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• Element of Performance (EP) 2 references operative progress note


progress note

– An operative progress note is entered immediately after the procedure

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1. Identifiers1. Identifiers

Hospital information– Name and address

– Patient’s medical record number

– Admit date/status

• IP, OP, SDS

Patient identifiers– Minimum of 2 required

Date of service

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2. Procedure Summary2. Procedure Summary Preamble (indication for procedure)

– Emergent/elective– Start and stop time

Pre‐ and post‐operative diagnosisDocumentation of additional diagnoses– Documentation of additional diagnoses

Title of procedure– Procedure performed– Procedure specific information

Surgeon, co surgeon, assistant surgeon AND credentials– Surgeon is responsible for procedure note

Anesthetic type and anesthesiologist Blood loss h

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Other– Type of internal fixation if appropriate– Hardware, components, grafts, drains– Complications– Tourniquet time– Material left in place

3. Procedure Story3. Procedure Story

Prep and draping of patient Summary of procedure Approach Protection of internal structures Complications and unusual services Estimate of blood loss and replacement Fluids given and invasive tubes, drains, catheters used Hardware or foreign bodies intentionally left in the

operative site Correct sponge and needle count Closure (including who performed it) Dressings applied Immediate postoperative condition

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4. Findings4. Findings

Summary of what was found during surgery Summary of what was found during surgery

Post‐op care and instructions

Patient’s condition when sent to recovery room

If patient was admitted or discharged and where?

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5. Additional Information 5. Additional Information

Approved abbreviations

– Log of abbreviations

Legibility

Corrections

Amendments

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Orthopedic HospitalYour town, USA

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1. Identifiers

2. Procedure Summary

3. Procedure Story

4. Findings

5. Additional Information ?

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SHE IS NUMB FROM HER TOES DOWN SHE IS NUMB FROM HER TOES DOWN

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JCAHO Standard R12.40JCAHO Standard R12.40

• Element of Performance (EP) 3

D t ti b h i i th t t ti l b fit i k– Documentation by physician that potential benefits, risks, or side effects, including potential problems related to recuperation were discussed

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Consent vs. Informed ConsentConsent vs. Informed Consent

Consent

• Diagnosis

Informed Consent

• Discussed proposed treatment Diagnosis

• Nature and purpose

• Risk and side effects

• Probability of success

• Consequences

• No guarantees

p p

• Discussed risks and alternatives

• Patient understood the discussion

• Patient had all questions answered to his/her satisfaction

P i d h• Questions answered

• Patient consented to the treatment

Written consent is not informed consent18

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Orthopedic HospitalYour town, USA

1. All procedures performed– Bundled procedures

2. Procedure details• Work described in detail

– Repair vs. reconstruction– Identify ligaments, nerves (what was done to

protect)

3. Preoperative and Postoperative diagnosis• Include new findings

4. Additional diagnosis codes coded to highest l l ifi itlevel specificity

• Supports medical necessity

5. Primary surgeon• Role of assistant surgeon (MD, DO) or assist at

surgery (PA, NP)• Medical necessity of assistant• Work assistant performed

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PATIENT HAS TWO TEENAGE CHILDREN, PATIENT HAS TWO TEENAGE CHILDREN, BUT NO OTHER ABNORMALITIES BUT NO OTHER ABNORMALITIES

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Problematic AreasProblematic Areas• Procedures included in heading but not in op note

• Procedures not in heading that are in op note

• Laparoscopic procedure billed as openLaparoscopic procedure billed as open

• Timeliness of documentation

• Incorrect terminology– Provider indicates “osteotomy”, op note describes ostectomy

• Modifier usage– Modifier 22‐what should be documented?

• Insurance– MVA vs. health insurance vs. WC

• Amendments/addendums

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Ortho Audit ToolOrtho Audit Tool(Courtesy of Ruby Woodward)(Courtesy of Ruby Woodward)

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REVIEWER

General Comments:

Recommendations:

CODER

Coder Signature: ____________________________________ Date: _________________

Reviewer Signature: ____________________________________ Date: _________________

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ON THE SECOND DAY THE KNEE WAS BETTER ON THE SECOND DAY THE KNEE WAS BETTER AND ON THE THIRD DAY IT DISAPPEARED AND ON THE THIRD DAY IT DISAPPEARED

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Office Procedure Office Procedure

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HEALTHY APPEARING DECREPIT 69HEALTHY APPEARING DECREPIT 69‐‐YEAR OLD YEAR OLD MALE, MENTALLY ALERT BUT FORGETFULMALE, MENTALLY ALERT BUT FORGETFUL

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EXAMINATION OF GENITALIA REVEALS EXAMINATION OF GENITALIA REVEALS THAT HE IS CIRCUS SIZEDTHAT HE IS CIRCUS SIZEDTHAT HE IS CIRCUS SIZEDTHAT HE IS CIRCUS SIZED

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OCCASIONAL, CONSTANT, OCCASIONAL, CONSTANT, INFREQUENT HEADACHES INFREQUENT HEADACHES

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RECTAL EXAMINATION REVEALEDRECTAL EXAMINATION REVEALEDA NORMAL SIZE THYROIDA NORMAL SIZE THYROIDA NORMAL SIZE THYROIDA NORMAL SIZE THYROID

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Day 1

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Day 1

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Day 2

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Day 2

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BOTH BREASTS ARE EQUAL AND REACTIVEBOTH BREASTS ARE EQUAL AND REACTIVETO LIGHT AND ACCOMMODATION TO LIGHT AND ACCOMMODATION

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THE SKIN WAS MOIST AND DRYTHE SKIN WAS MOIST AND DRY

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ICDICD‐‐9 to ICD9 to ICD‐‐1010

The Importance of DetailsThe Importance of Details

May 20,2013May 20,2013

After the stormAfter the stormKristi Dunn CPC,CGSC

Before the stormBefore the storm

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May 20,3013May 20,3013

• My son, daughter and her boyfriend’s 3 year old daughter took cover in the bedroom closet duringdaughter took cover in the bedroom closet during the tornado. They put a bicycle helmet on the 3 year old and my daughter held on to her and covered her up to protect her. My son put his body on top of both of them to shield them from the debris and they covered up with blankets. As the storm was bearing p gdown, my daughter described the sound as a paper shredder and thought it would never end.

continuedcontinued

• She held down on the little girl and then realized her brother was no longer in the closet with them butbrother was no longer in the closet with them but she couldn’t get up yet to go look for him because the tornado was still there. The noise stopped and she went searching for her brother calling his name. He was dazed but found on a pile of ruble about 50 feet from where they took shelter. He was unable to ystand and walk.

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continuedcontinued

• A passer by immediately took them to waiting ambulances staged at the damaged Moore medicalambulances staged at the damaged Moore medical center. Tacie received minor injuries to her arm and a chipped shoulder blade. The little girl she had been protecting only had a few scratches. Thank God she was wearing the bicycle helmet as it took a huge dent to the back of it.

TacieTacie

Brian Brian

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Procedures PerformedProcedures Performed

• 26608 Percutaneous skeletal fixation of metacarpal fracture, each bone 26608‐59, 26608‐59

• 27220‐51 closed treatment acetabulum fracture• 27220‐51 closed treatment acetabulum fracture

• 27193‐51 closed treatment pelvic ring fracture

• 12034‐59‐51 intermediate repair leg wound

• 12004‐59‐51 simple repair scalp, flank and buttock wounds

PercutaneousPercutaneousSkeletal FixationSkeletal Fixation

Brian’s InjuriesBrian’s InjuriesInjuryInjury ICDICD‐‐99 ICDICD‐‐1010

Superficial cuts and abrasions to the face

910.0 S00.81XAS01.81XA

Abrasion other part of head, initial encounterLaceration without foreign body of other part of head, initial encounter

Open fractures to the 3,4, 5th

metacarpals815.19 S62.303B

S62.305BS62.307B

Unspecified fx 3rd metacarpal, lt handUnspecified fx 4th metacarpal, lt handUnspecified fx 5th metacarpal, lt hand

Closed pelvic ring fracture 808.8 S32.811A Multiple fx pelvis with unstable disruption of pelvic ring

Closed acetabulum fracture 808.0 S32.409A Unspecified fracture of unspecified acetabulum

Open wound to the scalp 3cm 873.0 S01.01XA Laceration without foreign body scalp, initial encounter

O d fl k 2 8 9 4 S31 109A U ifi d d f bd i l llOpen wound flank 2 cm 879.4 S31.109A Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, initial encounter

Open wound buttock 4 cm 877.0 S31.809A Unspecified open wound of unspecified buttock, initial encounter

Open wound lower leg 12 cm 891.0 S81.802A Unspecified open wound, left lower leg, initial encounter

Cataclysmic storms, tornado E908.1 X37.1XXA Tornado, initial encounter

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The Clean UpThe Clean Up

Would any one like a Would any one like a used hot tub?used hot tub?

ResourcesResources

• http://www.aaos.org/news/aaosnow/apr10/managing1.asp

• http://www hcpro com/HIM‐247616‐8160/Auditing‐for‐• http://www.hcpro.com/HIM‐247616‐8160/Auditing‐for‐coding‐mistakes‐on‐outpatient‐orthopedic‐cases.html

• Orthopedic surgical auditing tool courtesy of Ruby Woodward

• Ingenix Coding Lab: Coding from the Operative Report

• Medical Record and Documentation Requirements by Kevin Townsend, CPME, CPC, CPMA and Beth Lensgraf, DC

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REVIEWER

General Comments:

Recommendations:

CODER

Coder Signature: ____________________________________ Date: _________________

Reviewer Signature: ____________________________________ Date: _________________

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Thank YOU for attending!Thank YOU for attending!

CEU #

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