Early ICD-10 audits indicate a learning curve for general surgeons

Train staff to code from the full operative note

Surgical coding staff sometimes think they cannot bill a diagnosis code that is not in the diagnosis list on the operative report. This false assumption causes coders to overlook many valid diagnoses because they do not read the report, which costs physicians money.

For example, if a surgeon performs an open abdominal procedure and finds that the gallbladder is thickened and inflamed and must be removed, the operative note should include the finding of acute cholecystitis (K81.0) and a description of the cholecystectomy performed. If this finding is omitted from the postoperative diagnosis list, staff should code it after finding it in the documentation.

The transition to the 10th revision of the International Classification of Diseases (ICD-10) has gone relatively smoothly, and some general surgery practices and departments of surgery already are asking private consultants for audits to verify that codes are being selected and submitted accurately to the Centers for Medicare & Medicaid Services. The results of these reviews indicate that, although most general surgeons are documenting and coding for ICD-10 at a basic level, they are underusing or overlooking several essentials. This column discusses some common problems with the transition to ICD-10 codes and solutions for correcting these issues.

Specificity and laterality

An overarching finding in recent general surgery coding and documentation audits is a lack of specificity resulting from the use of unspecified codes and the failure to code for laterality.

When treating a breast cyst, for example, the surgeon knows whether it is on the right or left breast, but he or she has to document the position so that the staff knows how to code for it and the payor knows how to reimburse for it. Similarly, when performing a lumpectomy for breast cancer, the surgeon needs to report the exact location (at the nine o’clock position, or in the upper, outer quadrant, for example); otherwise, the specific location will be indiscernible.

General surgeons in particular can improve their documentation for operating on neoplasms. For example, when coding for colon cancer, coders need to know which specific part of the colon was involved, such as sigmoid, ascending, or descending.The exact location is essential; providing a code for colon cancer alone is too imprecise.

These types of deficiencies can have a significant effect on reimbursement. Failing to code for laterality may result in a rejected claim and thereby delay payment.

A lack of specificity (not specifying which part of the colon was involved, for example) won’t necessarily cause a denial—at least not until October 1, when the one-year grace period for surgeons to transition to the use of correct ICD-10 codes ends. This year, many payors are passing through claims that lack some of this detail to give physicians a chance to learn the new system. However, payors will likely tighten their claims auditing systems this fall, at which point either the claim will be denied completely or payment will be lower than if more specific codes had been used.

That said, physicians are at times justified in using an unspecified ICD-10 code. When seeing a patient for the first time, for example, the specific diagnosis may be unknown. If the patient has a lesion and a biopsy is ordered to determine whether it is benign, it is acceptable to code the claim as “unspecified.” However, once the results are back from the lab, the claim should specify whether the lesion is malignant or benign.

Comorbidity codes

Many surgeons document the primary diagnosis and nothing else, assuming that if they are getting properly reimbursed using only the primary diagnosis, it is unnecessary to code for any other comorbidities. This thinking is shortsighted. Medicare and other payors are building the reimbursement databases of the future by using the diagnosis codes that physicians submit today. Coding for comorbidities, especially those that potentially affect patient care, offers a more complete picture of the patient’s health status and the complexity of care delivered. When comorbidities as secondary diagnoses are omitted, the payor sees only part of the patient’s story.

If a surgeon provides only part of the story, he or she likely will receive reduced reimbursement in the future. As Medicare and other payors move toward value-based reimbursement, comorbidity diagnoses will matter a great deal, and the number of comorbidities and other elements of a patient’s history are likely to affect the ability of surgeons and hospitals to negotiate bundled payments.

Payors also use the primary and comorbidity diagnoses to create and modify medical policies, as well as to determine whether a procedure was medically necessary.

Personal history codes

Personal history diagnosis codes are essential to accurate coding. Every personal history code should be reported and documented. If the surgeon removes a cancerous tumor from a patient with previous history of cancer, with or without removal of an organ, all of the cancer sites in the patient’s history should be reported.

Oncologists typically are good at reporting this history, but general surgeons frequently code only the primary site. “The patient has secondary lung cancer” is not enough information; coding staff needs the surgeon to report all of the sites, not just the primary location. This level of documentation is essential to the staff’s ability to code and bill all diagnoses.

As another example, if a patient has metastatic rectal cancer that has spread to the right lung, the brain, and the right adrenal gland and presents for partial colectomy with anastomosis, the surgeon should report the rectal cancer (C20) to support the procedure, as well as the metastatic sites: C78.01 for the right lung, C79.31 for the brain, and C79.71 for the right adrenal sites. If they are pertinent to the present encounter, report the patient’s personal history of cancer, chemotherapy, and radiation therapy.

Personal history codes also can support complexity and may support additional payment in some cases. If the surgeon performs abdominal surgery on a patient who had a prior partial colectomy and encounters dense adhesions that make repairing the site more complex, the coding staff could append the Current Procedural Terminology (CPT)* code with modifier 22 to indicate that the procedure was more complex or complicated than usual.

Modifier 22 is used to indicate that the case required more work than normal and that the physician should be paid for this increased work. Adding diagnosis codes for absence of part of the colon (Z90.49) and peritoneal adhesions (K66.0) may help support the additional fees charged, but this additional information must be documented in your report.

Physicians must tell the patient’s full story in the operative note or documentation for staff to research all of the codes that fully describe the case. Three pages of notes on the patient are not necessary; one or two detailed sentences or a few descriptive words that will help staff choose codes with the right specificity should suffice (see sidebar).

Overlapping sites

ICD-9 included codes for contiguous sites. In ICD-10, those codes were eliminated and replaced with overlapping sites codes. If the patient has a mass in the middle to lower esophagus, it is considered overlapping because it is not in the top, nor the middle, nor the lower. Instead of coding for middle and lower, choose one code for overlapping lesion.

Overlapping sites codes are an unusual concept in ICD-10 because they provide less specificity, while ICD-10 overall is driving more specificity. For example, if a patient has a malignant tumor in the colon that begins in the ascending colon and ends in the transverse colon, do not choose C18.2 (ascending colon) and C18.4 (transverse colon). The correct code to describe this is C18.8 (malignant neoplasm of overlapping sites).

In the neoplasm table in ICD-10, the overlapping codes are broken down by site and morphology. Some organs are further broken down to specific portions of an organ, like upper-outer quadrant of the breast or lower lobe of the lung. If a primary malignancy overlaps two or more sites that are contiguous, one code should be reported from the subcategory of the code with a fourth character of .8 (overlapping lesion) unless a specific combination code is available.

If the anatomic sites overlap, use overlapping lesion codes rather than codes for each distinct area. The choice of overlapping code series will depend on the part of the body.


While ICD-10 has many more codes than ICD-9, with attention to documentation, ICD-10 coding is manageable. Be as descriptive as possible in ICD-10 coding. Everything done to care for the patient should be documented in the operative report. Awareness of issues such as severity, laterality, specific location, chronicity, causation, and treatment encounter all increase the specificity of ICD-10 codes.

*All specific references to CPT codes and descriptions are ©2015 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.


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