Orthopedic Coding Alert

Signs and symptoms may sometimes be the best -- or only -- choice

Although the correct CPT code may indicate the work your orthopedist did, if you fail to attach the correct diagnosis code, you could be heading for denials.

 Follow these expert recommendations to ensure you-re properly coding patients- signs, symptoms and diagnoses.

1. Watch for 4th- and 5th-Digit Requirements

Correct coding requires that you be as specific as possible. That means your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.

You should always use the fourth or fifth digit when ICD-9 requires it -- or anytime you have that information. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated.

Pitfall: Don't assume what isn't in the medical record.

Example: If you are coding for a closed proximal humerus fracture, you cannot simply report 812.0, because four digits alone don't make for a complete diagnosis. Instead, you must specify a fifth digit of 0 (for an upper end fracture, unspecified part), 1 (for a surgical neck fracture), 2 (for an anatomical neck fracture), 3 (for a greater tuberosity fracture) or 9 (for an other upper humeral fracture, such as of the head, upper epiphysis or lesser tuberosity).

Tip: If the medical record does not allow you to code to the required specificity level, check with the reporting physician for guidance. -Physicians are notorious for this when it comes to osteoarthritis,- says Jill M. Young, CPC-EDS, of Young Medical Consulting LLC in East Lansing, Mich. -Without the notation of generalized or localized, you end up with a nonspecific code regardless of whether the physician told you where it was on the body.-

2. Call on Signs and Symptoms

When your physician provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If the physician cannot document a definitive diagnosis, however, report the patient's signs and symptoms to support medical necessity for services the physician provides.

Avoid -rule outs-: ICD-9 coding guidelines state that you should not report -rule out- diagnoses in the outpatient setting. You-ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, your physician will still get paid for his services, even if he cannot establish a definitive diagnosis.

-Look to see if the physician has given the patient a definitive diagnosis,- says Denae M. Merrill, CPC, physician coder for Covenant HIM in Saginaw, Mich. --Rule out,- -suspected,- -probable- or -questionable- are not codeable. If there is no definitive diagnosis given, look for any signs or symptoms that the patient has been having.-

Example: The orthopedist sees a pediatric patient who complains of pain just below the knee with some bruising and suspects that the girl has a hairline tibial fracture.

Correct coding in this instance depends on available documentation. If the physician states that the diagnosis is a hairline tibial fracture, report the relevant code (for example, 823.20, Fracture of tibia and fibula; shaft, closed; tibia alone). If the physician notes that he is attempting to -rule out- the fracture, you should report the signs and symptoms (for example, 729.5, Pain in limb; or 924.10, Contusion of lower leg, if appropriate).

Again: CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnosis. Instead, -code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ...-

Pointer: Talk to your physicians about how important it is to be accurate with their terms. Tell the physician that if he can come to a definite conclusion about the patient's diagnosis, he needs to state this in his dictation so you may choose the best code. -Remind your providers that you cannot and should not -give- someone a fracture by coding that as a diagnosis when it is really only suspected,- Young says.

3. Use V Codes When Applicable

Coders often hesitate to report V codes, but sometimes they may be the most accurate descriptors of the reason for the patient's condition. Actually, you should use V codes to provide additional clinical information to an insurer, whether it's Medicare or a private carrier.

Most coders believe that V codes are only appropriate as secondary codes, but the reality is that you may -- and on occasion should -- report V codes as a primary diagnosis. In some instances, a V code may even be the only way to be paid for a service.

-Don't be afraid to use a V code as a primary diagnosis,- Young says. -Many of the codes are payable. And, besides, it is the correct way to code if that is what the documentation states.-

Example: A Medicare patient who suffered a traumatic hip fracture returns to your practice for routine follow-up one year later. Because the patient no longer has a hip fracture, you shouldn't report 820.21 (Pertrochanteric fracture, closed; intertrochanteric section) for the visit one year after the patient's hip healed. Instead, you should report V67.4 (Follow-up examination; following treatment of healed fracture). In other words, because the hip fracture is no longer an acute condition, you can't use the fracture as your primary diagnosis.

Tip: Many versions of the ICD-9 manual indicate whether you can report a V code as a primary or secondary diagnosis using the indicators -PDx- (primary) and -SDx- (secondary) next to the code descriptor. If the code has neither a -PDx- nor an -SDx- designation, you may use that V code as either a primary or a secondary diagnosis, according to ICD-9 instructions.