Principles of Coding

Principles of Coding Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 8, 2009

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 2009 software can help

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

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

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

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

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

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

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

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.

Case Examples • Case 4 • Code set 883.1 / 99203 Complex lac / consultation 903.5 / 35207-F1 Repair blood vessel, direct; hand, finger 883.2 / 26356-F1-51 Repair, flexor tendon, in Zone 2 883.2 / 26350-F2-51 Repair, flexor tendon, not in Zone 2 955.6 / 64831-F1-51 Suture of digital nerve, hand or foot 955.6 / +69990 Microsurgical techniques • Local anesthesia included • Repair of skin included • Splinting included

Case Examples • Case 5 • 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

Case Examples • Case 5 • 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

Case Examples • Case 6 • 28 y/o female, MVA, multiple trauma • Initial eval with Grade IIIA R humerus fx • Taken to OR for urgent I&D and plating • Further workup 2 days later revealed nondisplaced sacral zone 1 fx; closed treatment

Case Examples • Case 6 • 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

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

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

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

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

Thank you

Principles of Coding