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Principles of Coding

Principles of Coding. Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 13, 2010. Lecture Outline. Terminology Code Organization Special Codes Modifiers Case Examples Tips for Op Report Dictation. Lecture Outline. Terminology Code Organization

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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

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