facility specific coding guideline establishing a default code based on common practice

jndgeiger@msn.com

Hello,

Has anyone developed an facility specific coding guideline establishing a default code based on common practice? We are interested in making one for greater saphenous vein harvesting for CABG.

I attached the coding clinic that mentions the internal policy. We have provided physician education and tip cards to post at dictation areas. The CDS were selecting greater based on education from the surgeons that the greater is always used for the vein harvest and also from using anatomy reference when location of excision of saphenous vein is documented in the operative note. Coding specialists are sharing feedback that the word "greater" or "lesser" is missing in the operative note and needs to be stated by the surgeon.

I appreciate your advise,
Julie

Julie Geiger, BS, RN, CCDS
Operational Lead Clinical Documentation Specialist
Parkview Health
Fort Wayne, Indiana
Phone: 260-266-1240
Email: julie.geiger@parkview.com

Unknown

It should be sort of easy if the doc mentions whether the vein was harvested from the front, medial side of the leg or the back, lateral side of the leg. This would mean that they'd have to lift the leg up and rotate it so as to get to the posterolateral aspect of the leg which, if you ask the vascular surgeons, they would dictate that part specifically. Otherwise, if they don't lift and rotate the leg, it will be the greater saphenous. Maybe that can help with the coding guideline for the hospital – “it’s always greater unless specifically stated to be lesser saphenous and this is what we’ll have to dictate.” (See attached)





Robert S. Gold, MD

CEO, DCBA, Inc

4611 Brierwood Place

Atlanta, GA 30360

(770) 216-9691 (Office)

(404) 580-0204 (Cell)

jndgeiger@msn.com

Thank you Dr. Gold. I will share your helpful information at our CDS and coding meeting next week.

Julie