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Medical Documentation and Coding for the Colorectal Surgeon
Introduction
One of the most essential and least understood issues affecting colorectal surgeons is accurate medical documentation and coding via the current procedural terminology (CPT) coding system. This coding system encompasses a broad framework for capturing the components of physician work and requires use of specific descriptors of the work performed to ensure transformation of the encounter into reimbursement via the various physician payment systems. In addition, the specificity of the required documentation should produce accurate coding to support more rapid reimbursement and decreases in payment denials, thus optimizing the revenue cycle. Many surgeons do not fully understand the power of accurate coding to produce granular analysis of code patterns, individual volumes, and resource consumption within a practice. These data, in turn, should be routinely assessed within a robust practice management system to define areas for process improvement for revenue, along with practice patterns to reduce waste and cost. It is essential that all physicians take the time and expend the effort to master the components of a code and the documentation required in the medical record to achieve the financial rewards and avoid the risk of Medicare fraud prosecution.
Process of CPT Code Development
CPT codes are developed under the direction of the American Medical Association (AMA) in conjunction with representatives from virtually all medical specialties. The steps in the process are: (1) identification of a new procedure/encounter and the unique and specific components of that activity by a specialty; (2) presentation of the procedural description to the CPT committee of the AMA by a specialty society and approval of a unique CPT code (Category 1 or Category 3, described later); (3) evaluation of the code using an elaborate survey of practitioners of the service to develop suggested relative value units (RVUs) to define physician work, practice expense, and professional liability values; (4) presentation of the suggested RVU value to the Relative Value Update Committee of the AMA for final code valuation and recommendation of this RVU value to the Centers for Medicare and Medicaid Services for acceptance or refinement; and (5) transformation of the code into approved reimbursement (defined by multiplying the existing $/RVU conversion factor multiplied by the accepted total RVU value). Although surgeons often complain about specific valuations, the system has generally provided sufficient “relativity” between procedures and services to be reasonably fair across specialties.
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