- Email: [email protected]
Correct coding for the orthopedic surgeon
Clin Sports Med 21 (2002) 237 – 244
Correct coding for the orthopedic surgeon M. Mike Malek, MD a,*, Melvin M. Friedman, MD b, William Beach, MD c a
Washington Orthopaedic and Knee Clinic, 8206 Leesburg Pike, Suite 201, Vienna, VA 22182, USA b Johns Hopkins Medical Institution, 8108 Anita Road, Baltimore, MD 21208, USA c Orthopedic Research of Virginia, 7605 Parham Road, Suite 301, MOB II, Richmond, VA 23294, USA
In this age of computers, it has become necessary to develop a universal language to describe medical diagnoses and procedures for the purposes of tracking, research, and reimbursement. It is essential that medical personnel describe events using common descriptors and that eponyms and regional variations be eliminated. To reach that goal, two coding systems have been developed and are being used in the United States almost exclusively. The International Classification of Diseases, 9th Edition [1] is the diagnostic coding system, and the American Medical Association’s (AMA’s) Current Procedural Terminology [2] is the procedural coding system.
Diagnostic coding The World Health Organization (WHO), based in Geneva, Switzerland, is responsible for developing diagnostic coding for the world. The coding system is revised and updated approximately every 15 years. The International Classification of Diseases 9th Edition (ICD-9 [1]) was developed in the late 1970s and was implemented in the early 1980s. Because this classification is used in all countries, it quickly became apparent that what would work in some of the small Third World countries would not be sophisticated enough for countries that were highly computerized. Thus was born the idea of a clinical modification. In the early 1980s in the United States, a publication known as ICD-9 Carriers Manual (CM) was adopted and ICD-10 will be released in the near future. It has an update mechanism under the auspices of the National Center for Health and Vital Statistics (NCHVS) and is updated quarterly. Meetings are held to discuss updates in Washington, D.C. at the Department of Health and Human Services building. Anyone may make suggestions for new or
* Corresponding author. 0278-5919/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 0 2 7 8 - 5 9 1 9 ( 0 2 ) 0 0 0 0 4 - 2
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revised coding. This system is an all-numeric system that has basically seven digits. The first three digits are broad categories followed by a period and up to four more digits to allow more subdivision and specificity. In the mid-1990s, the WHO developed ICD-10 in conjunction with many countries and many medical societies, including the American Academy of Orthopaedic Surgeons (AAOS). A clinical modification for the United States has been completed by NCHVS, again with a great deal of input within the parameters required by the WHO from the AAOS. This is an alpha-numeric system and is totally different from ICD-9CM. It is complete and is available for purchase. It is currently undergoing two different field tests that were to be completed by June 30, 2001. After that, it will be sent to the Congress, and, if approved, a 90-day notice will be published in the federal register. It could be implemented in 2003. A comprehensive crosswalk has been developed in hopes of making the transition as easy as possible, but this will be difficult, time consuming, and expensive.
Procedural coding In 1964, the AMA developed a small pamphlet called Current Procedural Terminology (CPT [2]). It was largely ignored, as was CPT-2. CPT-3 was developed by the AMA under the auspices of Burgess Gordon, MD, who expanded the publication and helped it gain credibility and acceptance. In the late 1970s, CPT-4 was published with the guidance of Asher Finkel, MD. In 1984, the Centers for Medicare and Medicaid Services (CMS) designated CPT-4 as the official procedural coding system for the Medicare program. As expected, within a very short time other third-party insurance carriers came to accept CPT-4, with a considerable amount of coercion; however, with the advent of new procedures and the desire for better coding specificity, CPT-4 [2] is quickly becoming unwieldy and antiquated. The AMA has convened multiple consensus panels and is now converting CPT-4 into CPT without number designation. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. CPT is continuously revised and therefore requires maintenance. An AMA committee known as the CPT Editorial Panel provides this maintenance. The Editorial Panel is made up of 16 physicians, 11 of whom are determined by the Board of Trustees of the AMA. One is the Health Care Professional Advisory Committee co-chairman, and Blue Cross and Blue Shield, the Insurance Association of America, the Health Care Finance Administration, and the American Hospital Association each nominate one. Supporting the Editorial Panel is the CPT Advisory Committee. This committee is comprised of members, primarily physicians, nominated by the national specialty societies represented in the AMA House of Delegates. They act as a resource for the editorial panel by giving advice on coding, providing docu-
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
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mentation on procedural appropriateness, suggesting CPT revisions, developing technical education material, and promoting and educating the AMA membership on CPT issues [3]. Requesting a new CPT code or changing an existing code follows a clearly defined process. First, a requestor must carefully consider the issues involved in requesting or changing a particular code. These issues include recognizing if the new code is consistent with the other codes in the category of codes, if the new code is a duplication of a pre-existing code, and if there is a combination of codes that would achieve the same coding goal. Once the requestor has accomplished this and believes a new code or change is needed, a Coding Change Request Form is obtained from the AMA. The success of the entire request process is related to the accuracy and completeness of the request form. Instructions provided in this form include ‘‘indicate the specific reasons why this code or coding change is necessary,’’ ‘‘specify the recommended terminology for the proposed code,’’ and ‘‘provide a clinical vignette which describes the typical patient and a description of the procedure.’’ The clinical vignette accompanies this request for the life of the request, and, therefore, a concise specific description of the patient and service or procedure must be scripted. The requestor must avoid information regarding services provided by other health care professionals (ie, descriptions of radiographs or MRI results). Currently, the request form is 10 pages long and contains 26 questions. After the request is complete, it is sent to the AMA where the staff reviews the form and determines if the question has already been considered. If it has been previously considered, then the AMA sends the requestor a response noting the Editorial Panel’s previous decision and the correct coding procedure. If the staff, advisors, or the CPT Advisory Committee members either agree with the coding change or if two or more disagree on the question, it is referred to the CPT Editorial Panel for consideration. The procedure or service is then investigated or researched by the staff and the CPT Advisory Committee. It is important for the requestor to provide appropriate data supporting the efficacy of the procedure. It is also essential that the requestor include the specialty society in the educational process. For example, the AAOS is represented in the AMA and on the CPT Advisory Committee, and AAOS support on coding changes or new codes for orthopedics is mandatory. The Editorial Panel can take three actions on the code request. It can add a new code or revise an existing code, table the item for further information and discussion, or reject the item [2]. If a new code is granted, then it can be of three categories. Category I codes are the working codes of CPT. These codes are given a five-digit CPT number and are then referred to the AMA/Specialty RVS Update Committee (RUC) for a Relative Value Unit assignment. An example of a newly granted and valued category I CPT code is arthroscopic rotator cuff repair. These codes are listed in the next edition of CPT. Category II codes are performance measurement codes and are intended to facilitate data collection by coding certain services or test results that are agreed upon as contributing to the positive health outcomes and quality patient care. These services are currently included in the
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Evaluation and Management (E/M) guidelines. Category III codes are emerging technology codes. The AMA has stated that this is an avenue for data collection on procedures that are new or have been previously coded as unlisted procedures. This allows physicians, the CMS, and third parties to separate the unlisted procedures codes and determine the number and types of procedures being performed that do not have category I CPT codes. Assignment of this code in no way implies the procedure is experimental but does mandate that there be ongoing clinical data collection for the procedure. These procedural listings are assigned an alphanumeric identifier with a letter as the first character (eg, T0001) and are not referred to the RUC for evaluation. Examples of orthopedic procedures that currently have been assigned tracking codes are meniscal transplantation (T0012) and allograft and autograft osteochondral transplantation (T0013 and T0014). If the Editorial Panel rejects the coding change, the requestor can appeal the decision in writing to the AMA. The appeal must include the reason for the appeal and should respond to the Panel’s rationale for denying the coding change. The Executive Committee of the AMA CPT Editorial Panel hears the appeal. They invite the requestor to be present and present dialogue on the issue. They make the final decision on the coding request. If they choose to reconsider the request, then the issue is referred back to the AMA staff and the Editorial Panel.
Coding and reimbursement Receiving timely and proper reimbursement under the present rules and regulations depends on several factors. In the following sections, the most important factors are summarized regarding coding and modifiers. Each orthopedic surgeon should become familiar with the coding process and not leave this critical issue to office staff. Correct coding is ultimately the responsibility of the physician. There are numerous publications on proper coding and seminars and courses offered throughout the year to educate the orthopedist in this process. The following are major areas that need special attention by the orthopedist and his/her staff to receive timely and proper reimbursement: Use of correct codes For each procedure performed, the orthopedic surgeon or the individual responsible for coding in the office should select the correct code or codes that include the proper diagnostic code (ICD-CM9 [1]) and the proper procedure code (CPT [2]). Careful attention should be given to matching the codes to the exact title and detail of the procedure according to what has been described in the operative report. Bundling rules Generally speaking, commercial carriers follow the lead of Medicare in deciding which procedures they will pay and how those procedures are
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
241
reported. These carriers also establish their own subset of rules. You need to understand and find out about the subset of rules from each carrier with whom you participate. The CMS initiated the Correct Coding Initiative, which seems to be a rebundling of CPT codes. Appropriate use of modifiers Modifiers are two-digit numerical descriptives that explain special circumstances or procedures, which is different from what a CPT code describes. Following is a list of modifiers listed in the CPT (2001) [2] book: -21 -22 -23 -24
Prolonged evaluation and management services Unusual procedural services Unusual anesthesia Unlisted evaluation and management services by the same physician during a postoperative period -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service -26 Professional component -32 Mandated services -47 Anesthesia by surgeon -50 Bilateral procedure -51 Multiple procedures -52 Reduced services -53 Discontinued procedure -54 Surgical care only -55 Postoperative management only -56 Preoperative management only -57 Decision for surgery -58 Staged or related procedure or service by the same physician during the postoperative period -59 Distinct procedural service -62 Two surgeons -66 Surgical team -76 Repeat procedure by same physician -77 Repeat procedure by another physician -78 Return to the operating room for a related procedure during the postoperative period -79 Unrelated procedure or service by the same physician during the postoperative period -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when a qualified resident surgeon not available) -90 Reference (outside) laboratory
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-91 Repeat clinical diagnostic laboratory test -99 Multiple modifiers Proper use of codes for follow-up The ICD-9CM states that categories V51 –V59 indicate a reason for care in patients who may have already been treated for some disease or injury not now present or who are receiving care to consolidate the treatment, to deal with residual states, or to prevent recurrence. One must distinguish between current care and aftercare. Global period The definition of a global surgical period is a lengthy one and is included in the Medicare Carriers Manual. In brief, most of the related services that occur immediately before and as many as 90 days after a surgery are part of the package payment for surgery; this period is called the ‘‘global period.’’ The global period for major surgery starts the day before and for minor surgeries the day of surgery. The global period applies only to the physician who performs the surgery.
Illustrative examples In this section we illustrate some common examples of coding. This section is not intended to be a complete guide for coding orthopedic and arthroscopic procedures. Example 1: therapeutic injections Coding for therapeutic injections and receiving proper reimbursement seems to be a challenge for orthopedic offices. The three most common injections administered by orthopedic surgeons are cortisone, Hyalgan, and Synvisc. In the case of a cortisone injection, there is a supply code, which is 18010, 10702, or 11030, depending on the substance used. If the injection is given at the time of the initial office visit for a new patient, then the office visit (9920299205) is billable separately from the injection code. The office visit is billable (99212-99215) for an established patient if the patient presents with a new complaint and the injection is done at the same visit. Although the Medicare guideline in this regard is fairly clear, you may need to consult each commercial carrier for their policies on injections. The substance code for Hyalgan is 17315, and the substance code for Synvisc is 17320. In addition to the code for the substance, the appropriate code for the arthrocentesis is used based on the size of the joint and the appropriate modifier for the site [4]. Generally, an E/M cannot be billed in addition to the arthrocentesis and substance code because these injections are planned in advance.
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Example 2: arthroscopy and chondroplasty The proper coding for arthroscopy with chondroplasty of patella, resection of the medial plica, and limited synovectomy is 29877 with no modifier or any other code. Example 3: arthroscopy with partial medial meniscectomy and chondroplasty lateral femoral chondroplasty In this scenario the chondroplasty is in the opposite compartment where the menisectomy has been performed; thus, 29881 and 29877-51 can be used. The modifier indicates that chondroplasty has been performed in another compartment. Example 4: arthroscopically assisted anterior cruciate reconstruction with repair medial meniscus Here code 29888 is used, with 29882 for meniscal repair and the modifier -51 to indicate a separate procedure. Example 5: bilateral total knee arthroplasty This can be coded in two ways: (1) with a two-line item, with the first line being 27447 and the second line being 27447-50, or (2) with a one-line item, 27447-50, which has a 2 in the units of service box. Category II codes are basically preventive medicine codes; category III codes are for tracking purposes only (ie, codes that need to be tracked because they are used frequently but have not been proven). Peer-review literature has not yet documented the effectiveness of these procedures, and there is no long-term follow-up. Examples are meniscal allograft, mosaicplasty, and OATS procedure. Three arthroscopic codes are being added: (1) distal clavicle resection, (2) arthroscopic shoulder capsulorraphy (nonthermal), and (3) arthroscopic repair of superior labral anterior-posterior lesion. The unlisted procedure code of 29909 will be changed to 29999, giving room for 90 new arthroscopic codes. Example 6: arthroscopy shoulder with debridement and shrinkage capsulorrhaphy The correct way of coding for this procedure, because there is no distinct CPT code, is 29999 (unlisted procedure) with a -59 modifier to indicate a distinct procedure from debridement. Depending on the type of debridement codes, 29822 or 29823 is used. Some carriers may require a -51 modifier. Example 7: arthroscopy with mini rotator cuff repair including subacromial decompression and distal clavicle resection In this scenario, code 23412 should be used as the primary code, with 29826-51 as the secondary procedure. For the excision of the distal clavicle, if
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it were done through the open incision and specifically was over 1 cm, the code 23120 (partial claviculectomy) can be used. Otherwise, 29824 should be used with a -51 modifier.
Summary Coding accurately is one of the main principles of a successful practice. Some changes that we will see shortly include deletion of the term ‘‘separate procedure,’’ deletion of the term ‘‘with and/or without,’’ deletion of the term ‘‘any method,’’ revision of the criteria for choosing E/M levels, and 52 new and revised Hand Surgery codes. Some other changes to come will be category II and category III codes. More changes are occurring as this is written, and the best advice is to stay tuned. It is obvious to the authors that coding is mainly for reimbursement purposes. The orthopedic surgeon must remain vigilant and must not pass this task on to someone else. Ignorance of coding methods is not an excuse [2]. We must all watch carefully and speak up when necessary. In this day of decreasing reimbursement, we can all increase our revenue stream without working any harder if we code our work properly, completely, and promptly.
References [1] International Classification of Diseases ICD-9-CM. American Medical Association Press; 2000. [2] Kirschner G, Kopacz J, Reyes D, et al. Current procedural terminology. Professional edition 2001. American Medical Association; 2000. p. 15. [3] CPT Process. American Medical Association; 1997. [4] CPT Assistant. Your practical guide to current coding. American Medical Association; 2000.
Further Readings Orthopedic coding alert, vol. 3. Naples, Florida: The Coding Institute; 2000. p. 88 – 91. Orthopedic coding alert, vol. 4. Naples, Florida: The Coding Institute; 2001. p. 21 – 3. Orthopedic coding alert, vol. 3. Naples, Florida: The Coding Institute; 2000. p. 54 – 5. American Medical Association at: www.ama-assn.org.
Correct coding for the orthopedic surgeon M. Mike Malek, MD a,*, Melvin M. Friedman, MD b, William Beach, MD c a
Washington Orthopaedic and Knee Clinic, 8206 Leesburg Pike, Suite 201, Vienna, VA 22182, USA b Johns Hopkins Medical Institution, 8108 Anita Road, Baltimore, MD 21208, USA c Orthopedic Research of Virginia, 7605 Parham Road, Suite 301, MOB II, Richmond, VA 23294, USA
In this age of computers, it has become necessary to develop a universal language to describe medical diagnoses and procedures for the purposes of tracking, research, and reimbursement. It is essential that medical personnel describe events using common descriptors and that eponyms and regional variations be eliminated. To reach that goal, two coding systems have been developed and are being used in the United States almost exclusively. The International Classification of Diseases, 9th Edition [1] is the diagnostic coding system, and the American Medical Association’s (AMA’s) Current Procedural Terminology [2] is the procedural coding system.
Diagnostic coding The World Health Organization (WHO), based in Geneva, Switzerland, is responsible for developing diagnostic coding for the world. The coding system is revised and updated approximately every 15 years. The International Classification of Diseases 9th Edition (ICD-9 [1]) was developed in the late 1970s and was implemented in the early 1980s. Because this classification is used in all countries, it quickly became apparent that what would work in some of the small Third World countries would not be sophisticated enough for countries that were highly computerized. Thus was born the idea of a clinical modification. In the early 1980s in the United States, a publication known as ICD-9 Carriers Manual (CM) was adopted and ICD-10 will be released in the near future. It has an update mechanism under the auspices of the National Center for Health and Vital Statistics (NCHVS) and is updated quarterly. Meetings are held to discuss updates in Washington, D.C. at the Department of Health and Human Services building. Anyone may make suggestions for new or
* Corresponding author. 0278-5919/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 0 2 7 8 - 5 9 1 9 ( 0 2 ) 0 0 0 0 4 - 2
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M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
revised coding. This system is an all-numeric system that has basically seven digits. The first three digits are broad categories followed by a period and up to four more digits to allow more subdivision and specificity. In the mid-1990s, the WHO developed ICD-10 in conjunction with many countries and many medical societies, including the American Academy of Orthopaedic Surgeons (AAOS). A clinical modification for the United States has been completed by NCHVS, again with a great deal of input within the parameters required by the WHO from the AAOS. This is an alpha-numeric system and is totally different from ICD-9CM. It is complete and is available for purchase. It is currently undergoing two different field tests that were to be completed by June 30, 2001. After that, it will be sent to the Congress, and, if approved, a 90-day notice will be published in the federal register. It could be implemented in 2003. A comprehensive crosswalk has been developed in hopes of making the transition as easy as possible, but this will be difficult, time consuming, and expensive.
Procedural coding In 1964, the AMA developed a small pamphlet called Current Procedural Terminology (CPT [2]). It was largely ignored, as was CPT-2. CPT-3 was developed by the AMA under the auspices of Burgess Gordon, MD, who expanded the publication and helped it gain credibility and acceptance. In the late 1970s, CPT-4 was published with the guidance of Asher Finkel, MD. In 1984, the Centers for Medicare and Medicaid Services (CMS) designated CPT-4 as the official procedural coding system for the Medicare program. As expected, within a very short time other third-party insurance carriers came to accept CPT-4, with a considerable amount of coercion; however, with the advent of new procedures and the desire for better coding specificity, CPT-4 [2] is quickly becoming unwieldy and antiquated. The AMA has convened multiple consensus panels and is now converting CPT-4 into CPT without number designation. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. CPT is continuously revised and therefore requires maintenance. An AMA committee known as the CPT Editorial Panel provides this maintenance. The Editorial Panel is made up of 16 physicians, 11 of whom are determined by the Board of Trustees of the AMA. One is the Health Care Professional Advisory Committee co-chairman, and Blue Cross and Blue Shield, the Insurance Association of America, the Health Care Finance Administration, and the American Hospital Association each nominate one. Supporting the Editorial Panel is the CPT Advisory Committee. This committee is comprised of members, primarily physicians, nominated by the national specialty societies represented in the AMA House of Delegates. They act as a resource for the editorial panel by giving advice on coding, providing docu-
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
239
mentation on procedural appropriateness, suggesting CPT revisions, developing technical education material, and promoting and educating the AMA membership on CPT issues [3]. Requesting a new CPT code or changing an existing code follows a clearly defined process. First, a requestor must carefully consider the issues involved in requesting or changing a particular code. These issues include recognizing if the new code is consistent with the other codes in the category of codes, if the new code is a duplication of a pre-existing code, and if there is a combination of codes that would achieve the same coding goal. Once the requestor has accomplished this and believes a new code or change is needed, a Coding Change Request Form is obtained from the AMA. The success of the entire request process is related to the accuracy and completeness of the request form. Instructions provided in this form include ‘‘indicate the specific reasons why this code or coding change is necessary,’’ ‘‘specify the recommended terminology for the proposed code,’’ and ‘‘provide a clinical vignette which describes the typical patient and a description of the procedure.’’ The clinical vignette accompanies this request for the life of the request, and, therefore, a concise specific description of the patient and service or procedure must be scripted. The requestor must avoid information regarding services provided by other health care professionals (ie, descriptions of radiographs or MRI results). Currently, the request form is 10 pages long and contains 26 questions. After the request is complete, it is sent to the AMA where the staff reviews the form and determines if the question has already been considered. If it has been previously considered, then the AMA sends the requestor a response noting the Editorial Panel’s previous decision and the correct coding procedure. If the staff, advisors, or the CPT Advisory Committee members either agree with the coding change or if two or more disagree on the question, it is referred to the CPT Editorial Panel for consideration. The procedure or service is then investigated or researched by the staff and the CPT Advisory Committee. It is important for the requestor to provide appropriate data supporting the efficacy of the procedure. It is also essential that the requestor include the specialty society in the educational process. For example, the AAOS is represented in the AMA and on the CPT Advisory Committee, and AAOS support on coding changes or new codes for orthopedics is mandatory. The Editorial Panel can take three actions on the code request. It can add a new code or revise an existing code, table the item for further information and discussion, or reject the item [2]. If a new code is granted, then it can be of three categories. Category I codes are the working codes of CPT. These codes are given a five-digit CPT number and are then referred to the AMA/Specialty RVS Update Committee (RUC) for a Relative Value Unit assignment. An example of a newly granted and valued category I CPT code is arthroscopic rotator cuff repair. These codes are listed in the next edition of CPT. Category II codes are performance measurement codes and are intended to facilitate data collection by coding certain services or test results that are agreed upon as contributing to the positive health outcomes and quality patient care. These services are currently included in the
240
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
Evaluation and Management (E/M) guidelines. Category III codes are emerging technology codes. The AMA has stated that this is an avenue for data collection on procedures that are new or have been previously coded as unlisted procedures. This allows physicians, the CMS, and third parties to separate the unlisted procedures codes and determine the number and types of procedures being performed that do not have category I CPT codes. Assignment of this code in no way implies the procedure is experimental but does mandate that there be ongoing clinical data collection for the procedure. These procedural listings are assigned an alphanumeric identifier with a letter as the first character (eg, T0001) and are not referred to the RUC for evaluation. Examples of orthopedic procedures that currently have been assigned tracking codes are meniscal transplantation (T0012) and allograft and autograft osteochondral transplantation (T0013 and T0014). If the Editorial Panel rejects the coding change, the requestor can appeal the decision in writing to the AMA. The appeal must include the reason for the appeal and should respond to the Panel’s rationale for denying the coding change. The Executive Committee of the AMA CPT Editorial Panel hears the appeal. They invite the requestor to be present and present dialogue on the issue. They make the final decision on the coding request. If they choose to reconsider the request, then the issue is referred back to the AMA staff and the Editorial Panel.
Coding and reimbursement Receiving timely and proper reimbursement under the present rules and regulations depends on several factors. In the following sections, the most important factors are summarized regarding coding and modifiers. Each orthopedic surgeon should become familiar with the coding process and not leave this critical issue to office staff. Correct coding is ultimately the responsibility of the physician. There are numerous publications on proper coding and seminars and courses offered throughout the year to educate the orthopedist in this process. The following are major areas that need special attention by the orthopedist and his/her staff to receive timely and proper reimbursement: Use of correct codes For each procedure performed, the orthopedic surgeon or the individual responsible for coding in the office should select the correct code or codes that include the proper diagnostic code (ICD-CM9 [1]) and the proper procedure code (CPT [2]). Careful attention should be given to matching the codes to the exact title and detail of the procedure according to what has been described in the operative report. Bundling rules Generally speaking, commercial carriers follow the lead of Medicare in deciding which procedures they will pay and how those procedures are
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
241
reported. These carriers also establish their own subset of rules. You need to understand and find out about the subset of rules from each carrier with whom you participate. The CMS initiated the Correct Coding Initiative, which seems to be a rebundling of CPT codes. Appropriate use of modifiers Modifiers are two-digit numerical descriptives that explain special circumstances or procedures, which is different from what a CPT code describes. Following is a list of modifiers listed in the CPT (2001) [2] book: -21 -22 -23 -24
Prolonged evaluation and management services Unusual procedural services Unusual anesthesia Unlisted evaluation and management services by the same physician during a postoperative period -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service -26 Professional component -32 Mandated services -47 Anesthesia by surgeon -50 Bilateral procedure -51 Multiple procedures -52 Reduced services -53 Discontinued procedure -54 Surgical care only -55 Postoperative management only -56 Preoperative management only -57 Decision for surgery -58 Staged or related procedure or service by the same physician during the postoperative period -59 Distinct procedural service -62 Two surgeons -66 Surgical team -76 Repeat procedure by same physician -77 Repeat procedure by another physician -78 Return to the operating room for a related procedure during the postoperative period -79 Unrelated procedure or service by the same physician during the postoperative period -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when a qualified resident surgeon not available) -90 Reference (outside) laboratory
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M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
-91 Repeat clinical diagnostic laboratory test -99 Multiple modifiers Proper use of codes for follow-up The ICD-9CM states that categories V51 –V59 indicate a reason for care in patients who may have already been treated for some disease or injury not now present or who are receiving care to consolidate the treatment, to deal with residual states, or to prevent recurrence. One must distinguish between current care and aftercare. Global period The definition of a global surgical period is a lengthy one and is included in the Medicare Carriers Manual. In brief, most of the related services that occur immediately before and as many as 90 days after a surgery are part of the package payment for surgery; this period is called the ‘‘global period.’’ The global period for major surgery starts the day before and for minor surgeries the day of surgery. The global period applies only to the physician who performs the surgery.
Illustrative examples In this section we illustrate some common examples of coding. This section is not intended to be a complete guide for coding orthopedic and arthroscopic procedures. Example 1: therapeutic injections Coding for therapeutic injections and receiving proper reimbursement seems to be a challenge for orthopedic offices. The three most common injections administered by orthopedic surgeons are cortisone, Hyalgan, and Synvisc. In the case of a cortisone injection, there is a supply code, which is 18010, 10702, or 11030, depending on the substance used. If the injection is given at the time of the initial office visit for a new patient, then the office visit (9920299205) is billable separately from the injection code. The office visit is billable (99212-99215) for an established patient if the patient presents with a new complaint and the injection is done at the same visit. Although the Medicare guideline in this regard is fairly clear, you may need to consult each commercial carrier for their policies on injections. The substance code for Hyalgan is 17315, and the substance code for Synvisc is 17320. In addition to the code for the substance, the appropriate code for the arthrocentesis is used based on the size of the joint and the appropriate modifier for the site [4]. Generally, an E/M cannot be billed in addition to the arthrocentesis and substance code because these injections are planned in advance.
M.M. Malek et al / Clin Sports Med 21 (2002) 237–244
243
Example 2: arthroscopy and chondroplasty The proper coding for arthroscopy with chondroplasty of patella, resection of the medial plica, and limited synovectomy is 29877 with no modifier or any other code. Example 3: arthroscopy with partial medial meniscectomy and chondroplasty lateral femoral chondroplasty In this scenario the chondroplasty is in the opposite compartment where the menisectomy has been performed; thus, 29881 and 29877-51 can be used. The modifier indicates that chondroplasty has been performed in another compartment. Example 4: arthroscopically assisted anterior cruciate reconstruction with repair medial meniscus Here code 29888 is used, with 29882 for meniscal repair and the modifier -51 to indicate a separate procedure. Example 5: bilateral total knee arthroplasty This can be coded in two ways: (1) with a two-line item, with the first line being 27447 and the second line being 27447-50, or (2) with a one-line item, 27447-50, which has a 2 in the units of service box. Category II codes are basically preventive medicine codes; category III codes are for tracking purposes only (ie, codes that need to be tracked because they are used frequently but have not been proven). Peer-review literature has not yet documented the effectiveness of these procedures, and there is no long-term follow-up. Examples are meniscal allograft, mosaicplasty, and OATS procedure. Three arthroscopic codes are being added: (1) distal clavicle resection, (2) arthroscopic shoulder capsulorraphy (nonthermal), and (3) arthroscopic repair of superior labral anterior-posterior lesion. The unlisted procedure code of 29909 will be changed to 29999, giving room for 90 new arthroscopic codes. Example 6: arthroscopy shoulder with debridement and shrinkage capsulorrhaphy The correct way of coding for this procedure, because there is no distinct CPT code, is 29999 (unlisted procedure) with a -59 modifier to indicate a distinct procedure from debridement. Depending on the type of debridement codes, 29822 or 29823 is used. Some carriers may require a -51 modifier. Example 7: arthroscopy with mini rotator cuff repair including subacromial decompression and distal clavicle resection In this scenario, code 23412 should be used as the primary code, with 29826-51 as the secondary procedure. For the excision of the distal clavicle, if
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it were done through the open incision and specifically was over 1 cm, the code 23120 (partial claviculectomy) can be used. Otherwise, 29824 should be used with a -51 modifier.
Summary Coding accurately is one of the main principles of a successful practice. Some changes that we will see shortly include deletion of the term ‘‘separate procedure,’’ deletion of the term ‘‘with and/or without,’’ deletion of the term ‘‘any method,’’ revision of the criteria for choosing E/M levels, and 52 new and revised Hand Surgery codes. Some other changes to come will be category II and category III codes. More changes are occurring as this is written, and the best advice is to stay tuned. It is obvious to the authors that coding is mainly for reimbursement purposes. The orthopedic surgeon must remain vigilant and must not pass this task on to someone else. Ignorance of coding methods is not an excuse [2]. We must all watch carefully and speak up when necessary. In this day of decreasing reimbursement, we can all increase our revenue stream without working any harder if we code our work properly, completely, and promptly.
References [1] International Classification of Diseases ICD-9-CM. American Medical Association Press; 2000. [2] Kirschner G, Kopacz J, Reyes D, et al. Current procedural terminology. Professional edition 2001. American Medical Association; 2000. p. 15. [3] CPT Process. American Medical Association; 1997. [4] CPT Assistant. Your practical guide to current coding. American Medical Association; 2000.
Further Readings Orthopedic coding alert, vol. 3. Naples, Florida: The Coding Institute; 2000. p. 88 – 91. Orthopedic coding alert, vol. 4. Naples, Florida: The Coding Institute; 2001. p. 21 – 3. Orthopedic coding alert, vol. 3. Naples, Florida: The Coding Institute; 2000. p. 54 – 5. American Medical Association at: www.ama-assn.org.