Orthopedic Coding Alert

Outpatient E/M visits sometimes uncover problems so severe that the orthopedist orders immediate emergency surgery. If you admit such patients directly to the hospital, you should report only the initial hospital care code (99221-99223), not the outpatient E/M code (99201-99215).

Emergency surgery can cause many coding issues. Consider the following excerpts from an Arkansas subscriber's operative note:

"This 32-year-old male patient removed a large splinter from his right index finger about two weeks ago but suffered such severe pain and swelling that he can no longer flex his finger. I told the patient that this is a surgical emergency requiring immediate irrigation and drainage (I&D) of the flexor tendon sheath, and advised that his flexor tendon may have suffered complete necrosis. I admitted the patient to the hospital and performed a surgical release of the flexor tenosynovitis by two-incision technique with a closed-irrigation method. This included inserting a #8 French catheter through the flexor tendon sheath proximally for about 2 cm. He tolerated the surgery well and will return for follow-up visits at one and two weeks postoperatively."

Although the orthopedist dictated separate notes for both the outpatient and inpatient evaluations, he should not report both E/M visits separately.

CPT states, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., physician's office ...) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission."

You can consider your outpatient evaluation "bullets," however, when determining the hospital admission code level. "With that in mind, this physician should report one of the initial hospital care codes (99221-99223)," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J. "Despite high-complexity medical decision-making, the physical exam in this note is so localized that it only qualifies as a 99221."

CMS'documentation guidelines mandate that you must document a comprehensive examination, including a general multi-system examination or complete examination of a single organ system, to qualify for codes 99222 or 99223.

Stout recommends reporting 26020 (Drainage of tendon sheath, digit and/or palm, each) for the surgery, along with the ICD-9 codes 727.05 (Other tenosynovitis of hand and wrist), 041.9 (Bacterial infection, unspecified) and 906.1 (Late effect of open wound of extremities without mention of tendon injury). "Inserting the catheter is an integral part of this surgery and should not be reported separately," she says.

Because Medicare would normally bundle a same-date E/M code into the surgical global period, you should append modifier -57 (Decision for surgery) to 99221. "This is especially true since last year, when CPT revised its definition of what is included in a surgical package," says Billie Jo C. McCrary, CPC, CPC-H, CCS-P, RMC, coding coordinator at Wellington Orthopaedic and Sports Medicine, a Cincinnati practice.

CPT states that a surgery includes "Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure, including history and physical."

"Modifier -57 communicates to the payer that the E/M service should not be included in the surgical procedure and should be paid separately," McCrary says. "Keep in mind that appeals are sometimes necessary to prove that the circumstances were not those of a regularly scheduled, preplanned surgery."

Medicare considers the patient's postoperative visits part of the global surgical package, Stout says, but you can assign 99024 (Postoperative follow-up visit, included in global service) for each of them. The August 1998 CPT Assistant advises, "To report a postoperative follow-up visit for documentation purposes only, use 99024." Medicare will not reimburse you for the service, but many orthopedists use 99024 to track their postoperative visits.