Orthopedic Coding Alert

The new musculoskeletal codes may hold the most exciting changes for orthopedic coders in the new year, but you-ll also benefit from changes to the modifier descriptors and the E/M codes.

The most dramatic modifier change is that the descriptor for modifier 22 will change from "unusual procedural services" to "increased procedural services."

According to CPT 2008, the physician's work must be "substantially greater than typically required" to warrant using modifier 22. And your documentation must support the "substantial additional work." You must also document the reasons why the doctor had to work harder, such as increased intensity, added time, the procedure's technical difficulty, severity of the patient's condition, or physical and mental effort required.

The new language sounds a lot tougher than the old wording, but you-ll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach for the American Academy of Professional Coders in Salt Lake City.

Modifier 59 changes: The description for modifier 59 (Distinct procedural service) now says that "documentation must support" that there was a separate session or distinct service. Cobuzzi says she's been teaching all along that your documentation must support modifier 59. "They-re just clarifying it because there's been so much abuse on 59."

CPT 2008 will debut several new E/M codes that will benefit orthopedic practices, but half of them are simply replacements for codes removed from CPT 2008. For instance, medical team conference codes 99361 and 99362 have been deleted and replaced by three all-new codes:

Codes 99366-99368 differ from their predecessors (99361-99362) in several ways. First, 99366 and 99368 apply to nonphysician healthcare professionals (NPPs), such as a nurse, nurse practitioner, physician assistant, etc. Both code descriptors specify a minimum service time of 30 minutes or more, but 99366 also stipulates that the patient and/or family be present during the conference.

"These codes [99366 and 99368] were added to allow the inclusion of nonphysician, qualified healthcare professionals," says Susan E. Garrison,-CHC, PCS, FCS, CCS-P, CPAR, CPC,-CPC-H, executive vice president of Healthcare Consulting Services.

-Patient presence matters: Many payers, including Medicare, will not reimburse separately for non-face-to-face services -- which means insurers will likely not recognize 99368 (during which the patient and/or family is not present) as a payable service. There is a possibility, however, that payers may choose to accept 99366 if an NPP in your practice takes part in a team conference for a patient in your care, as long as the patient and/or family is involved.

Code 99367 also requires a service time of 30 or more minutes, but applies when a physician (rather than an NPP) participates in the team conference. In this case, the patient and/or family are not present.

Previous codes 99361 and 99362 also described physician participation in a team conference, but because those codes specified "patient not present," Medicare and other payers would not reimburse for the services. Because 99367 is likewise not a face-to-face service, payers will almost definitely not pay for it. -

CPT 2008 does not contain a code for a team conference with both physician (rather than NPP) and patient and/or family involvement. In such a case (that is, when both a physician and patient are present for a counseling service), the physician should report a standard E/M code (such as established patient visit 99211-99215) based on counseling and coordination of care time, Garrison says.

"Be sure to alert your physicians," Garrison says, "that counseling and coordination of care time must be documented."

-Dial Up New Telephone Codes

The AMA has updated and replaced the telephone service codes several times in the past few years, and once again in 2008, you-ll have all-new codes -- with fresh descriptors -- to apply to these services:

- 99441 -- Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

- 99442 -- - 11-20 minutes of medical discussion

- 99443 -- - 21-30 minutes of medical discussion.

Previous telephone service codes 99371-99373 (deleted for 2008) described a "telephone call by a physician to a patient or for consultation or medical management or for coordinating medical management with other healthcare professionals." The precise services named by these new codes are considerably narrower. The telephone service must be unrelated to any previous service within the past week, and the telephone service should not lead to a face-to-face evaluation within the next 24 hours. If you provide phone counseling and then see the patient within 24 hours or the next available visit, you forfeit the call code.