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Principles of Coding

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  1. Principles of Coding Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 18, 2012

  2. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  3. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  4. Terminology • Global package • Pre-op H&P • Consent • Local anesthesia • Surgery • Simple wound irrigation • Intra-op x-rays • Suture removal • Post-op follow-up (0, 10, 90 days)

  5. Terminology • Current Procedural Terminology (CPT) • Code breakdown • 10% pre-op assessment • 69% surgery • 21% post-op follow-up care

  6. Terminology • Relative Value Unit (RVU) • Total • Work • Facility vs. non-facility • How they generate a new code

  7. Case • Elbow fracture, surgery with ulnar nerve exposure • Codes • Elbow ORIF alone • Wound irrigation with elbow ORIF • Wound irrigation with elbow ORIF and ulnarneuroplasty

  8. Case • Elbow fracture, surgery with ulnar nerve exposure • Codes • Elbow ORIF alone • Wound irrigation with elbow ORIF • Wound irrigation with elbow ORIF and ulnarneuroplasty

  9. Case • Open elbow fracture with ring/small finger numbness, surgery with ulnar nerve exposure • Codes • Elbow ORIF alone • Wound irrigation with elbow ORIF • Wound irrigation with elbow ORIF and ulnarneuroplasty

  10. Case • Open elbow fracture with ring/small finger numbness, surgery with ulnar nerve exposure • Codes • Elbow ORIF alone • Wound irrigation with elbow ORIF • Wound irrigation with elbow ORIF and ulnarneuroplasty

  11. Terminology • Correct Coding Initiative (CCI) Edits • Bundled services • Prep and drape • Local anesthesia by surgeon • Surgery (open, closed, percutaneous) • Drains and pumps at same surgical site • Cultures • Access through damaged tissue; repair • Intra-op complications and management

  12. Terminology • Modifiers • Procedure altered in circumstance • Procedural definition unchanged • Two-digit attached to CPT code

  13. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  14. Code Organization • Sections • 10000 Skin and nails • 20000 Orthopaedic • 30000 Vascular • 60000 Neurosurgery • 90000 Medicine (includes wound care)

  15. Code Organization • Orthopaedic section • Spine • Shoulder • Humerus and Elbow • Forearm and Wrist • Hand and Fingers • Pelvis and Hip • Femur and Knee • Leg and Ankle • Foot and Toes

  16. Code Organization • Categorical • Incision • Excision • Introduction or Removal • Repair, Revision, Reconstruction • Fracture and Dislocation • Arthrodesis • Amputation • Other

  17. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  18. Special Codes • Symbols • Modifier -51 exempt • Add-on code • 64831 Suture of digital nerve • 64832 each additional nerve • 69990 use of operative microscope • Revised code • New code • Service includes surgical procedure only • 20550 Injections; tendon sheath

  19. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  20. Modifiers • Patient had morbid obesity, and femur nailing took twice as long

  21. Modifiers • Patient had morbid obesity, and femur nailing took twice as long • Femur IMN -22

  22. Modifiers • Patient taken to OR for femur IMN, but because BP dropped upon induction, anesthesia canceled the case

  23. Modifiers • Patient taken to OR for femur IMN, but because BP dropped upon induction, anesthesia canceled the case • Femur IMN -53

  24. Modifiers • Open elbow fracture with ulnar nerve injury, undergoing ORIF and I&D

  25. Modifiers • Open elbow fracture with ulnar nerve injury, undergoing ORIF and I&D • ORIF • I&D -51 • Ulnarneuroplasty -51-59

  26. Modifiers • Day 1 • ORIF of distal radius • Day 14 • Repeat ORIF because of collapse

  27. Modifiers • Day 1 • ORIF of distal radius • Day 14 • Repeat ORIF because of collapse • Day 1: Radius ORIF • Day 2: Radius ORIF -78

  28. Modifiers • Day 1 • ORIF of distal metaphyseal radius • Day 14 • Repeat ORIF because poor fixation of unrecognized intra-articular split

  29. Modifiers • Day 1 • ORIF of distal metaphyseal radius • Day 14 • Repeat ORIF because poor fixation of unrecognized intra-articular split • Day 1: Radius ORIF • Day 2: Radius intra-artic ORIF -58

  30. Modifiers • Day 1 • I&D of forearm wound, but still needing second debridement • Day 5 • Repeat I&D of forearm wound

  31. Modifiers • Day 1 • I&D of forearm wound, but still needing second debridement • Day 5 • Repeat I&D of forearm wound • Day 1: I&D, and DICTATE PLAN • Day 2: I&D -58

  32. Modifiers • -22: Unusual procedural services • Scarring, bleeding, obesity, etc. • 25% fee increase • Must quantify extent of complexity

  33. Modifiers • -50: Bilateral procedure • Payment is 150% of the single code • -51: Multiple procedures • Payment at 50% (100-50-50-50-50) • Doesn’t always apply; some codes are exempt • 51 modifier exempt codes • Add-on codes

  34. Modifiers • -53: Discontinued procedure • Surgery or anesthesia started, but case terminated due to certain circumstances

  35. Modifiers • -54: Surgical care only • Bills surgical portion of CPT • -55: Postoperative management only • Bills for post-op component of CPT

  36. Modifiers • -58: Staged procedure • Must meet ONE of the following: • Planned prospectively, or • Second stage more extensive than first, or • Definitive surgery after a diagnostic procedure • This sets the global period clock • Example: • Closed tx of distal radius, then to OR for open treatment

  37. Modifiers • -59: Distinct procedural service • Used to bypass CCI edits ONLY when appropriate • Situations (same calendar day services) • Separate incision • Separate area • Separate diagnosis • Separate session

  38. Modifiers • -78: Return to OR during post-op period • For post-op complications (that don’t meet -58 conditions) • Global period does not reset • Payment reduction

  39. Modifiers • -79: Unrelated procedure during post-op period • Make sure there is a new diagnosis • New global period established • Track both global periods separately

  40. Modifiers • Finger and toes • FA: Left Thumb • F1: Left Index Finger • … • F9: Right Small Finger • TA, T1–T9: Toes

  41. Lecture Outline • Terminology • Code Organization • Special Codes • Modifiers • Case Examples • Tips for Op Report Dictation

  42. Case Examples • Principles to remember • Everything you DO has a CPT code • E/M • Casting • Closed reduction • ORIF • Every CPT code must have a valid REASON (ICD-9 code) • Add modifiers when circumstances dictate • AAOS’s Code X 2012 software can help

  43. Case Examples • Case 1 • 10 y/o patient falls on scooter • Displaced R radius and ulna shaft fxs • Angulated L radius and ulna shaft fxs

  44. Case Examples • Case 1 • You perform open treatment of the R radius and ulna fxs, and closed manipulation and splinting of the L side.

  45. Case Examples • Case 1 • Code set 719.43 / 99244-57 Wrist pain / outpt consult, with decision for surgery 813.20 / 25574 Open tx R radius/ulna shaft fxs 813.20 / 25565-51-59 Closed manipulation of L radius/ulna shaft fxs • -51: Multiple procedure • 50% discount • 59: Distinct procedural service on the same day • Separate site

  46. Case Examples • Case 2 • 25 y/o patient falls from motorcycle • R open distal radius displaced intra-artic fx • Manipulation performed in ED for preliminary stabilization • Taken to OR that evening • I&D of open fx • ORIF

  47. Case Examples • Case 2 • Code set 884.10 / 99244-57 Complex open wound / consult, decision for surgery 813.52 / 25605 Closed tx radius with manip in ED 813.52 / 25620-59 Open tx radius in OR 813.52 / 11012-51-59 I&D of skin to bone assc with open fx • -51: Multiple procedure • 50% discount • -59: Distinct procedural service on the same day • Separate session

  48. Case Examples • Case 3 • 25 y/o patient falls from motorcycle • R distal radius displaced intra-artic fx • Manipulation performed in ED for preliminary stabilization • 5 days later, to OR • ORIF

  49. Case Examples • Case 3 • Code set 719.43 / 99244-57 Wrist pain / outpt consult, with decision for surgery 813.42 / 25605 Closed tx radius with manip in ED, with plan for surgery 813.42 / 25620-58 Open tx radius in OR, 5 days later • -58: Staged or related procedure • Planned prospectively • Subsequent procedure more extensive

  50. Case Examples • Case 4 • A 31-year-old carpenter, new patient in your clinic. • Exploration 3 days later revealed • Flexor tendon to his index finger in “Zone 2” and another to his long finger “not in Zone 2” • Severed the ulnar digital nerve IF • Lac ulnar digital artery IF • You perform debridement of all nonviable tissue was performed with repair of both flexor tendons. The procedure also included repair of the digital artery and nerve with an operating microscope followed by a simple repair of the wounds overlying the tendon and neurovascular injuries. A short-arm splint was applied.