May 3, 2022 | By Michele Strickland, CPC, CEMA
Research has been on my mind a lot lately. As auditors it is very important that we continually “exercise” our research muscle to make sure we are looking at our auditing from all angles. Rarely is our world black and white, so it is very important that we look at guidelines from different perspectives to make sure we are getting the whole picture. We must go beyond the “surface” to understand why we are making the decision we are making.
I recently ran into a scenario where I was being questioned on my decision regarding the definition of a major vs. minor surgical procedure. My answer to this seemed quite simple but ended up being a good reminder of the importance of research. You might be asking why I paused to consider my answer to this question as the AMA gave us a definition in the 2021 Documentation Guideline. The definition reads:
“Surgery (minor or major, elective, emergency, procedure, or patient risk): Surgery–Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. “
It is clear that the AMA states major vs. minor is not defined by the surgical package. The classification is now going to rely heavily on provider documentation for us to determine the difference between the two. The definition from AMA seems to answer the question until you look at the Medicare NCCI Coding Policy Manual. Per the NCCI Coding Policy Manual, Medicare defines major vs. minor surgical procedures based on the global period.
“If a procedure has a global period of 090 days, it is defined as a major surgical procedure.”
“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure.”
So, what is the answer to this question about defining major vs. minor surgical procedures?
Research……when we see guidance and contradictions such as this, as I said earlier, we must look at the whole picture. By whole picture I am referring to what the guidelines state at the “base” AMA level and then looking at who is paying the claim. When presented with these types of scenarios the AMA is a great starting point, but we must go further and research payer policy – as they are the entity that reimburses the claim – to determine what guidance to follow.
Research can seem a bit overwhelming. We have the internet at our fingertips where we can type a question and end up with thousands of results. While some of these results may be a good jump off point, they can also lead us to misinformation. It is because of this that my biggest advice when doing research is to know who your payers are and where they keep their policies and practice navigating those websites. It is important that you understand where to find the information to create consistency within your organization and to use for defense if needed. Once you have that information tucked away, it is equally important to check back for changes to make sure the information stays relevant.
In closing, I want to encourage you to know the WHY. Early on in my career I had a great mentor who instilled in me the importance of research to know the why behind my coding/auditing decisions. Even when we ask a question and are given an answer, it’s ok to ask for the WHY. While we are sometimes met with the answer “because that’s how it’s always been done,” it is still important to find the source. Have those discussions with your team members, and continue to dig into the payer policy to determine the WHY.
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