Orthopedic Coding Alert

Code the condition your ortho treats first, followed by co-morbidity.

If you think you can bill only one diagnosis code per claim, you could be unintentionally sending your claim to limbo land. Find out how your ICD-9 codes can complete your patients story and even boost your claims success.

Use All the Appropriate ICD-9 Codes

Dont believe the myth that you can bill only one diagnosis code.

Fact: Based on physician documentation, you should bill as many diagnosis codes as you need to establish medical necessity for the services youre billing, says  Kerry Sheskier, billing manager CPBS at Orthopaedic Dept./Physical Therapy of Winthrop Hospital in Bethany, N.Y. Medicare will process up to eight diagnosis codes.

I always think of ICD-9 coding as telling a story,says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, compliance and coding supervisor at Proliance Orthopedics and Sports Medicine in Bellevue, Wash. The more complete your story, the more likely youll answer all of your carriers questions and get your claim processed.

Remember: When reporting multiple diagnoses, you should report only the codes that apply to the situation at hand and those that may change the outcome of treatment, says Patrice A. Young, CPC, CMSCS, senior coder at Commonwealth Orthopaedic Associates in Reading, Pa. You should note that not all underlying conditions are appropriate -- such as when the patient has a cold and cough but fell and fractured her ankle.

Apply These Concepts to This Situation

Scenario: Your surgeon submitted the following operative note, but you cant determine which ICD-9 code applies. Should you report all diagnoses or just one?

A frayed and detached superior anterior labrum with detachment of the junction of the anterior superior and anterior portion of the labrum and about 90 percent detachment of the anterior aspect of the labrum right at the biceps tendon anchor. Some fraying of the posterior superior labrum but no detachment, and no detachment of the biceps tendon anchor itself. The patient had some synovitis,especially anteriorly and superiorly.

No evidence of any rotator cuff tear. The middle glenohumeral ligament was somewhat frayed, and the patient did appear to have some subtle laxity anteriorly, increased from the opposite side both on exam under anesthesia and when viewing through the arthroscope. The remainder of the patients labrum appeared normal. The subacromial space appeared without any significant synovitis, and the rotator cuff looked intact looking at it superiorly.

Solution: Your first step is to code the condition the physician is treating first, followed by the co-morbidity (if applicable), and then the mechanism or injury or reason for the condition, if known, Young says.

If the patient suffered shoulder joint instability, you should report 718.31 (Recurrent dislocation of joint; shoulder region). If not, you instead should use 719.91(Unspecified disorder of joint; shoulder region).In addition, you can add 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) for the labral tear.

Why: The documentation notes up to 90 percent detachment of the labrum. Ensure, however, that the documentation includes an injury date before you add this code.

Although the insurers computer will scan only the first, main diagnosis code listed, it is a good idea to list all the codes that apply. That way, if the payer challenges a claim, you can help your appeal by having already sent the insurer all the applicable diagnoses on record for the patient.

Reap the Benefits of Thorough Coding

Not only will your claims soar to success if you attach the appropriate codes, but you also can bolster your bottom line.

For instance, when you submit two or more CPT procedure codes, having unique ICD-9 code(s) for each procedure will support medical necessity. In other words,you could link 727.61 (Complete rupture of rotator cuff) to 29827 (Arthroscopy, shoulder, surgical; with rotator  cuff repair) and link 715.11 (Osteoarthrosis, localized, primary; shoulder region) to 29824 (Arthroscopy,shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure]). The separate diagnoses support the separate procedures.

When youre reporting an E/M code, all your diagnoses will support the complexity of the encounter or increase the complexity of the medical decision making component, Stumpf says.

Bonus: If you use modifier 22 (Increased procedural services) on a surgical code, your ICD-9 codes can paint the picture of what led to the increased work (such as excessive bleeding, scarring, etc.), Stumpf says. This will possibly help carriers reimburse your claim appropriately at the initial submission. You almost always, however,need an appeal letter documenting the rationale for this modifier.