AAP Survey Overview

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AAP Survey Overview

• William J. Cromie, MD FAAP

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Observations

• In the future, provide full operative notes. What
  is unstated creates problems for coders.
• Conservative versus aggressive coding. Chose two
  or more codes when one code adequately described
  service performed.
• Modifier 22 appeared inappropriate for cases
  submitted. However, included in 10 of
  responses.

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Observations Continued

• National coding guidelines are black and white.
  Software can only edit the codes submitted.
• Documentation may be required for support when
  multiple codes are submitted.
• Submission of incidental procedures, e.g. CPT
  code 66425(injection of anesthetic agent) per the
  CPT Surgical Package Definition section,is
  considered incidental to the procedure and would
  not be paid separately

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Case Presentation Case 3

• 6 month old male with chordee without
  hypospadias. Procedure performed Phalloplasty
  with rotation of dorsal preputial flaps to cover
  the ventral penis along with removal of excess
  prepuce. Corporal body plication performed to
  correct chordee.
• 54304 Plastic operation on penis for correction
  of chordee or for first stage hypospadias repair
  with or without transplantation of prepuce and/or
  skin flaps, described all of the elements of the
  procedure.
• 54300 Plastic operation of penis for
  straightening of chordee (e.g., hypospadias),
  with or without mobilization of urethra.
• 54360 Plastic operation of penis to correct
  angulation.

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Case 3 Survey Results
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Unbundling Example Case 3

• Survey example- provider submitted five codes
• 54300, 14040, 13131, 64430 and 54161
• 54300 recognized and accepted.
• Code 64430(Injection) would be considered
  global.
• Code 54161(Circumcision)is frequently performed
  with other hypospadias procedures and would be
  considered incidental.
• Neither of the above codes would be paid
• Codes 14040 and 13131 would require additional
  medical documentation to support whether a
  separate repair was needed.

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Industry Standards

• Multiple procedure processing
• Code auditing software
• Plans found non-compliant or How Aetna got in
  trouble
• Up-coding and fraud laws Federal False Claims
  Act, USC 3729-3733 for medicare and medicaid
  fraud, or How Tenet Healthcare got to pay back
  900 million to the federal govt.

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Take-Aways

• Keys to correct coding
• Use current updated CPT Manuals
• Document, Document, Document!
• Be realistic in coding
• Use modifiers judiciously
• 22-unusual procedure,
• 59-distinct procedure,
• 76-repeat by same MD,
• 77-repeat by another MD,
• 78-return to OR for related procedure,
• 79-return to OR for unrelated procedure or
  service by same MD

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Case 1 Survey Results
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Case 2 Survey Results
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Case 4 Survey Results
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Case 5 Survey Results