Written by Ladonna Schaad, CCS-P, CPC – Coding Compliance Manager

At times, screw or implant documentation for each screw or implant used during a procedure may be inadvertently missing from an operative report. For the time when the number of implants is completely missing from the report, the coder will have to request that information from the facility causing a delay in coding and reimbursement. When implant documentation is provided but there is no cross reference, a coder would be unaware that there might be an incorrect count.

Something_MissingA further complication is when there is a discrepancy between the operative report and the invoice. Occasionally, the implants will be bought in bulk for multiple cases represented by a single invoice. It would be next to impossible for coders to verify the specific number used on each individual patient except from the count from the physician’s operative report.

During a recent review, it was found that, in a comparison between the implant log and the implant documentation of a procedure, there was a discrepancy between the two documents. The physician was asked to document an addendum detailing the use of additional implants. No one intentionally forgets to document something but these are charges that may cumulatively cost the facility over time.

There have been a number of recommendations put forth to remedy this problem. In a perfect world, each facility would cross-reference to their implant logs and/or invoices against the physician operative reports to enable physicians to amend their documentation as quickly as possible should a discrepancy be found before submitting charges to coding with the amended reports. Failing that possibility, sending the implant log along with the charges submitted for cross-verification or sending an invoice for each individual case utilizing implants would also be an option. This, then, would raise the question of a discrepancy being placed into a pending status (which could quickly add up) or would each facility make the decision of which document would determine the final coding? No one choice seems to fits all.

As audits and utilization review focus more and more on capturing all revenue, the opportunity to ensure accurate coding through diligent verification of implant usage becomes more important. Make sure your surgery center is following guidelines for the proper screw and implant documentation procedures.

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