Orthopedic Coding Alert

Billing for additional time spent in counseling and the coordination of care presents a challenge. Coding at the higher evaluation and management (E/M) level can bring a denial if documentation is not included to show the amount of time spent with the patient or the patients family, and the reason the additional time was necessary. But detailed documentation justifying the higher level will bring the appropriate reimbursement for the additional physician time.

According to CPT 2000, reporting 99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: comprehensive history, comprehensive examination, medical decision-making of high complexity) means meeting a criterion in which physicians typically spend 40 minutes face-to-face with the patient and/or family. Moreover, using 99215 indicates the other established patient codes have been eliminated as choices.

Why would an orthopedist spend more time in coordination and/or counseling than in intervention? A series of clinical examinations might be needed or a review of diagnostic tests might be necessary simply to decide on an intervention (e.g., evaluating the choice between a brace or surgery for a ligament injury). Or a patient with undiagnosed, early-stage Alzheimers disease might exhibit severe anxiety over a surgery option, such as a total hip replacement. Such a patient will require thorough counselingprobably with a family member presentabout the procedure before a decision for surgery can be made. (See the related article on V codes, page 29.)

Action-oriented Nature of Orthopedic Practice

William J. Mazzocco Jr., president of Medical Administrative Support Services, a medical consultant firm in Altoona, Pa., believes he knows why E/M codes in the established patient category cause so many problems in orthopedic practices. Orthopedics has always been an action-oriented specialty from the initial clinical exam, up to and including the surgical intervention. [Consequently,] the procedure code took precedence over any E/M code that might have been generated by the encounter.

Code 25605 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; with manipulation) is often the appropriate choice when billing for an intervention such as Colles fracture. But Mazzocco explains there are instances when orthopedists must document and bill the E/M to obtain legitimate reimbursement for their services.

Patients with ancillary problems are not the only ones who require more time. Patients are taking a more active role in their own care, says Mazzocco. That means patients have more questions and require more detailed explanations from the physician.

Mazzocco gives the example of an orthopedist reviewing an MRI (magnetic resonance image) of the kneeand evaluating health risks, benefits and options with a patient who is [...]