Orthopedic Coding Alert

Correct these common mistakes to fend off claim denials

Because orthopedic surgeons frequently report reductions to treat dislocated joints, an audit of your reduction claims could cost your practice dearly. Investigate the three biggest suspects of incorrect claims, and make sure that your reporting standards can withstand carrier scrutiny.
 
Mistake #1: Reporting -With Anesthesia Codes for Local Anesthesia

Your surgeon performs an interphalangeal dislocation repair with a nerve block to manage the patient's pain during the reduction. Should you report 26770 (Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia) or 26775 (... requiring anesthesia)? After all, the nerve block served as the patient's anesthesia for that date.

The correct code in this situation is 26770, because payers don't consider the nerve block enough to qualify for the -with anesthesia- code.

-Medicare considers reduction of dislocated joints -with anesthesia- to indicate that there was a need for general anesthesia or monitored anesthesia care (MAC),- states the policy of Cahaba GBA, a Part B carrier in Mississippi, Alabama and Georgia.

In fact, two different physicians must normally participate in the procedure to qualify for the -with anesthesia- code. -Most carriers agree that the orthopedic surgeon would perform the surgical procedure, and a separate physician would perform the general anesthesia to qualify for those codes,- says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Mistake #2: Billing Separately for Anesthesia

You-re clear now that your surgeon should report 26770 for the joint reduction, but he also wants to bill a digital nerve block code such as 64450 (Injection, anesthetic agent; other peripheral nerve or branch). Can you report both?

The answer is no. -Do not allow separate payment for the anesthesia service performed by the physician who also furnished the medical or surgical service,- says Section 15018 of the Medicare Carriers Manual. -For example,- the MCM states, -do not allow separate payment for the surgeon's performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure.- And CPT guidelines include a digital block in the surgical package.

Mistake #3: Failing to Report Allowable E/M Services

Suppose your surgeon performs a level-three evaluation of an established patient's elbow dislocation and then decides to perform a reduction to treat the problem. Can you report both the E/M and the reduction?

You can report both services, as long as the patient has not already been diagnosed (for instance, by an emergency department physician), the documentation reflects a separately identifiable E/M service, and you append the appropriate modifier, says Catherine Estrada, CCS-P, coder at the Tucson Orthopaedic Institute in Arizona. In most cases, -the surgeon would have to do medical decision-making before deciding how to treat the injury,- she says.

Choose Between Applicable Modifiers

 If the E/M service revealed that the patient required a reduction, you should append modifier 57 (Decision for surgery) to the E/M code. Therefore, your claim would appear as follows:

- 24600 (Treatment of closed elbow dislocation; without anesthesia)
- 99213-57 (Office or other outpatient visit).

If the surgeon performs an E/M service for a separate problem on the same date of the elbow dislocation reduction, you should instead use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

According to WPSIC, a Part B payer in Wisconsin, Illinois, Michigan and Minnesota, -It is sometimes appropriate to perform a separately identifiable E/M service (using the 25 modifier) to evaluate the patient for other injuries and/or illnesses.-