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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 13, 2010

  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. 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

  34. 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

  35. 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 / 25608-59 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

  36. 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

  37. 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 / 25608-58 Open tx radius in OR, 5 days later • -58: Staged or related procedure • Planned prospectively • Subsequent procedure more extensive

  38. Case Examples • Case 4 • 62 y/o diabetic female, had R carpal tunnel surgery last month • Presents with new L LF/RF triggering • Patient seen in clinic during post-op period • Injections of LF/RF performed in clinic

  39. Case Examples • Case 4 • Code set 354.0 / 99214-24-25 Outpt established pt; new problem, minor procedure 727.03 / 20550-79-F2 Injection LF tendon sheath 727.03 / 20550-79-F3 Injection RF tendon sheath • -24: Unrelated E/M service during post-op • -25: Significant E/M on same day of surgery • -79: Unrelated procedure in the post-op period • -F2: L LF • -F3: L RF

  40. Case Examples • Case 5 • 28 y/o female, MVA, multiple trauma • Initial eval with Grade IIIA R humerusfx • Taken to OR for urgent I&D and plating • Further workup 2 days later revealed nondisplaced sacral zone 1 fx; closed treatment

  41. Case Examples • Case 5 • Code set 884.1 / 99245-57 Complex open inj / outpt consult, decision for surgery 812.31 / 24515 Open tx of humerusfx 812.31 / 11012-51 I&D of skin to bone for open fx 808.43 / 27193-79 Closed tx of pelvic fx without manipulation • -51: Multiple procedure • -79 modifier: Unrelated procedure during post-op • No fee reduction • Global period for humerus and pelvis separate

  42. Case Examples • Case 6 • If sacral fx and humerus treated on same day: • Code set 99245-57 Outpt consult, decision for surgery 24515 Open tx of humerusfx 11012-51 I&D of skin to bone for open fx 27193-51 Closed tx of pelvic fx without manipulation • -51: Multiple procedure • 50% fee reduction

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

  44. Tips for Op Report Dictation • Pre- and post-op diagnosis • Use ICD-9 terminology • Procedure • Use CPT language • Each procedure with corresponding diagnosis • Indications for surgery • Pt age • Reason for surgery • Previous related surgery

  45. Tips for Op Report Dictation • Findings • Include things such as • Length of wound, size of skin graft • Extensiveness of surgery (for modifier -22) • Details • One-to-one correlation with listed procedures • Separate into paragraphs • Plan • Facilitates post-op care • Allows future use of -58 modifier

  46. Review • Global service concept • Code organization • Body part • Category • Diagnosis :: Procedure • Documentation to justify EVERY code • Paragraph breakdown • Code every surgery, immediately

  47. Thank you