DEPARTMENT OF SURGERY Cardiothoracic Surgery Dentistry, Oral & Maxillofacial Surgery, Otolaryngology – Head & Neck Surgery General Surgery Neurosurgery Orthopaedic Surgery & Rehabilitation Medicine Pediatric Surgery Plastic & Reconstructive Surgery Transplant Surgery Urology Vascular Surgery New E-Billing Coding Profees from the Operative Report Author: Diane P. Bryant, MA, CPC Special thanks to: John McGarey & Anil Lal

Department of Surgery Profees Page 2 BENEFITS OF E-BILLING Eliminates paper charge sheet Enhances revenue Improves lag time submission Decreases redundant paperwork Creates faster, more efficient, cleaner claims Improves communication and trust Allows on-line review of E-Billing history Recent audits of charges billed from the operative report show claims are paid faster.

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Department of Surgery Profees Page 4 OPERATIVE REPORTS Operative report, with CPT, modifier and diagnosis codes, must be dictated and signed by attending (only signed reports can be billed). To conform to new and revised 2007 CPT codes, documentation should: – Meticulously describe surgical procedure(s) performed; and – Paint a clear and complete picture of the procedure performed to enable coders to determine that correct code(s) have been assigned. If accurate and precise CPT code cannot be determined from documentation, coder will contact physician for clarification to ensure documentation holds enough detail to accurately report procedure(s). Determination of CPT codes is based on physician documentation, not coder assumptions. Modified coding requires a letter of medical necessity forwarded to Profees Office (please include patient name, DOS, and MRN).

Department of Surgery Profees Page 5 CLAIMS PROCESSING Within 24 hours of dictation, operative report is transcribed by MedQuist, sent back to HIM (op tracking), and uploaded to Oasis and Soft Med for attending to review and finalize with his/her signature on ESA. Signed operative reports are uploaded to Profees system on date received. Using Encoder Pro, coder reviews charges for inconsistent codes and CMS Correct Coding Initiative compliance. Errors are held until coder makes necessary corrections. Clean claims are sent electronically to UCPG. KEY FACTORS FOR SUCCESS TIMELY DICTATION SIGNING THE OPERATIVE REPORT MEDICAL NECESSITY DOCUMENTATION