9/13/2013 1 Surgical Auditing for Orthopedics Presented by Barbara Fontaine, CPC Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC 1 Agenda • Documentation • Consent • Auditing • ICD-9-CM to ICD-10-CM example 2 Documentation Purpose • Outlines logic used in treating patient • Brief history of the problem • Demonstrates why a particular surgery was performed • Pre-and post-operative information • Consent to treat • Basis for reimbursement • Supports medical necessity 3
Transcript
9/13/2013
1
Surgical Auditing for Orthopedics
Presented by
Barbara Fontaine, CPC
Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC
1
Agenda
• Documentation
• Consent
• Auditing
• ICD-9-CM to ICD-10-CM example
2
Documentation Purpose
• Outlines logic used in treating patient
• Brief history of the problem
• Demonstrates why a particular surgery was performed
• Pre-and post-operative information
• Consent to treat
• Basis for reimbursement
• Supports medical necessity
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Documentation
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DISCHARGE STATUS: ALIVE BUT WITHOUT PERMISSION
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Elements of Operative note
1. Identifiers
2. Procedure Summary
3. Procedure Story
4. Findings
5. Additional Information
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1. 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 Summary
Preamble (indication for procedure) – Emergent/elective – Start and stop time
Pre- and post-operative diagnosis – 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 Other
– Type of internal fixation if appropriate – Hardware, components, grafts, drains – Complications – Tourniquet time – Material left in place
3. 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. Findings
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
Approved abbreviations
– Log of abbreviations
Legibility
Corrections
Amendments
Orthopedic Hospital Your town, USA
1. Identifiers
2. Procedure Summary
3. Procedure Story
4. Findings
5. Additional Information ?
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SHE IS NUMB FROM HER TOES DOWN
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Consent vs. Informed Consent
Consent
• Diagnosis
• Nature and purpose
• Risk and side effects
• Probability of success
• Consequences
• No guarantees
• Questions answered
Informed Consent
• Discussed proposed treatment
• Discussed risks and alternatives
• Patient understood the discussion
• Patient had all questions answered to his/her satisfaction
• Patient consented to the treatment
Written consent is not informed consent 14
Orthopedic Hospital Your 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 level 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, BUT NO OTHER ABNORMALITIES
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Problematic Areas • Procedures included in heading but not in op note
ON THE SECOND DAY THE KNEE WAS BETTER AND ON THE THIRD DAY IT DISAPPEARED
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Office Procedure
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HEALTHY APPEARING DECREPIT 69-YEAR OLD MALE, MENTALLY ALERT BUT FORGETFUL
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EXAMINATION OF GENITALIA REVEALS THAT HE IS CIRCUS SIZED
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OCCASIONAL, CONSTANT, INFREQUENT HEADACHES
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RECTAL EXAMINATION REVEALED A NORMAL SIZE THYROID
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Day 2
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BOTH BREASTS ARE EQUAL AND REACTIVE TO LIGHT AND ACCOMMODATION
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THE SKIN WAS MOIST AND DRY
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God bless my family
ICD-9 to ICD-10
The Importance of Details
After the storm
May 20,2013
Kristi Dunn CPC,CGSC
Before the storm
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May 20,3013
• My son, daughter and her boyfriend’s 3 year old daughter 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 down, my daughter described the sound as a paper shredder and thought it would never end.
continued
• She held down on the little girl and then realized her brother 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 stand and walk.
continued
• A passer by immediately took them to waiting ambulances 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.
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Tacie
Brian
Procedures Performed
• 26608 Percutaneous skeletal fixation of metacarpal fracture, each bone 26608-59, 26608-59
• 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
Percutaneous Skeletal Fixation
Brian’s Injuries Injury ICD-9 ICD-10
Superficial cuts and abrasions to the face
910.0 S00.81XA S01.81XA
Abrasion other part of head, initial encounter Laceration without foreign body of other part of head, initial encounter
Open fractures to the 3,4, 5th metacarpals
815.19 S62.303B S62.305B S62.307B
Unspecified fx 3rd metacarpal, lt hand Unspecified fx 4th metacarpal, lt hand Unspecified 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
Open 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
