The chant of the medical coder always comes in handy. When in doubt or faced with incomplete documentation, remember: “If the doctor didn’t say it, it wasn’t done.” Period.

When the documentation is missing or ambiguous, it’s your responsibility to clarify with the physician. Although some physicians become defensive or irritated when the coder questions the documentation, those who under- stand that your questions can maximize their reimbursement will gladly amend the documentation to clear up the problem.

Time to play “Name that Illness!” Upon reading the operative report or office notes, you must identify the illness or disease and find the corresponding diagnosis code in the International Classification of Diseases (ICD) book, Volumes 1 and 2.

After finding the diagnosis codes, you then look up the procedure codes that best describe the work done, using one of the following books:

✓ The Current Procedural Terminology (CPT) book: The CPT book con- tains all the procedure codes as determined by the American Medical Association (AMA) and includes the definition of each procedure. Physicians and outpatient facilities choose a code from the CPT book.

✓ The ICD-9 Volume 3 book: Hospital inpatient procedures are chosen from the ICD-9 Volume 3 book.

Because so many different codes and corresponding procedures exist, you may suffer from “coding drama.” Coding a procedure with a lot of moving parts can get a bit complicated. Sure, capturing all the procedures that were performed during a surgery is important, for example, but they each must be separately billable or have involved extra work by the surgeon in order to jus- tify unbundling them (or billing them separately). The point? Coding can get
pretty complicated. Before you panic, keep this in mind: Coding a procedure is simple if you remember to break it down into small bites.

Physician coding

Physician coding is just what it sounds like: coding diagnoses and proce- dures representing the work performed by a physician. Under certain cir- cumstances, work performed in an outpatient setting, such as an ambulatory surgery center (ASC), also uses physician coding.

Physician offices, ambulatory surgery centers, and other outpatient facili- ties use the CPT code sets to represent the procedure performed. Physician claims are submitted on the HCFA/CMS-1500 claim form. In most circum- stances, facilities bill commercial carriers on the UB-04 claim form. Both of these forms are discussed later in this chapter.

Facility coding
Coding for facility reimbursement often pertains to hospital coding. Specific coding and billing guidelines exist for hospital billing. If you are working as
a facility coder in a hospital, you use Volume 3 of the ICD-9 book to identify the procedures.

Basically, facility coding is for the hospital inpatient setting. Outpatient cen- ters, including those run by the hospital, use physician coding.