Orthopedic Coding Alert

Find out if you can use a modifier to separate these edits.

Every Jan. 1 brings code changes, and every New Year the Correct Coding Initiative (CCI) adds non-mutually exclusive edits to the new codes featured in CPT® 2014.

“As is customary for the first update of a given year, there are a lot of new edit pairs: 61,120 to be exact,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Factor in the number of terminations (13,107) and we see a net gain this coming quarter of 48,013 new edit pairs.”

For orthopedic coders, the version 20.0 edits bring several edits that may affect your claims. Read on to learn about the phone/Internet consultation code edits you need to apply to your Q1 coding.

Think Twice Before Reporting 99446-99449

Medicare has bundled all of the new Interprofessional consultation codes into a slew of orthopedic procedures. The bundled codes are 99446-99449.

Rationale: This reflects Medicare’s policy of never paying for non-face-to-face services or consultations and the CPT® guidelines, which state you cannot bill these codes if the patient has a face-to-face encounter with the consultant within the last 14 days.

“With relatively few exceptions, the modifier indicator associated with these edit pairs is ‘0,’ so you will not be able to override the edit with a modifier,” observes Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians. “Since the inter-professional consultation code is the Column 2 code in each case, it will be the code that is denied in favor of the procedural code reported on the same date,” adds Moore. So, if you are planning on reporting these codes separately with any other procedural codes, you’ll have to check CCI edits to see if these codes are paired.

Reminder: CCI 20.0 also pairs these codes as Column 2 codes with E/M service codes. So, you cannot report these codes if you are reporting any other E/M service code for the same session also. Note that these pairings also carry the modifier indicator ‘0’ which means that you cannot undo these edits by using any modifiers.

Example: Your orthopedist sees a 35-year-old new patient for complaints of knee replacement pain. The patient was being seen by another physician in another state. But the other physician was unable to manage and monitor the patient as the patient transferred out of that state. Your orthopedist sees the patient, reviews previous records and test results, and records a complete history of the patient. He also performs an examination of the patient and orders some tests, which are done while the patient is in the office.

After receiving the results of the tests, your orthopedist discusses the patient’s condition and treatment/management options that were performed by the previous physician by making a call to that physician on the same day.

Your physician discusses the management options that were followed by the previous physician and provides information about the present pain and inflammation; he also discusses further treatment options with the previous physician. Your physician spends a total of 15 minutes over the phone discussing the patient with the other physician.

Since you report the evaluation of the patient with a new patient E/M code for the session, you will not be able to report the time spent by physician on the same date in discussion with the other physician about the patient’s condition with 99447 (Inter-professional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review). CCI 20.0 bundles the E/M code and 99447 with the modifier indicator of ‘0.’ Plus, the patient is being seen within the 14 day window.

Heads up: They have also permanently bundled the two transitional management codes (99495-99496) into all surgical procedures as well.