Orthopedic Coding Alert

When it comes to ICD-9 coding, you can't believe everything you hear

You assigned the correct CPT codes and appended all of the required modifiers, but the carrier still denied your claim. You may be a victim of some common diagnosis coding myths that made you assign incorrect ICD-9 codes to your claim.
 
The following orthopedic coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement.

Myth 1: Once you precertify, you can't add diagnoses. You precertified a surgery based on one diagnosis, but after the orthopedist started the surgery he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right?
 
Not so fast. You can either precertify a code range or submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, coding and auditing department supervisor at Orthopedic Specialists of the Carolinas in Winston-Salem, N.C.
 
Suppose the orthopedist diagnoses a torn anterior cruciate ligament (ACL, 844.2) and acquires the insurer's preapproval to perform an ACL repair (29888). Once the orthopedist begins surgery, he also discovers a torn lateral meniscus (836.1) that the radiologist was unable to read on the MRI. The orthopedist then repairs the meniscus (29882) and ACL during the same session and reports both codes with the torn ACL and torn meniscus diagnoses.  
 
Because the insurer preauthorized only the surgery based on the torn ACL diagnosis, should the practice report both procedures?
 
Yes, but you can avoid this challenge if you precertify a code range rather than just one code, Fulton says. "Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says.

Precertify a Code Range Instead of One Code

"When we call the insurer to precertify a knee scope, we give the code range of 29870-29889 for certification purposes," Fulton says. "We tell the insurance company's pre-cert department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."
Insurers rarely ask surgeons to precertify just one CPT and diagnosis code.
 
In rare cases, however, the insurer might ask you to simply precertify the intended procedure based on the confirmed diagnosis. "In this case, we would of course give them the 29888 for the ACL repair, but we would reiterate that it is completely possible that more procedures will be performed and reported."
 
If, after the surgery, the insurance company balks at paying for the meniscectomy, the surgeon should write an appeal letter citing the date his practice requested preapproval, the fact that the practice attempted to precertify a code range, and that he diagnosed a torn meniscus using the arthroscope.

Myth #2: You can no longer report signs and symptoms as primary diagnoses. CMS program memorandum AB-01-144, released in 2002, stated that if the physician confirms a diagnosis, he should report that diagnosis instead of the signs or symptoms that prompted the procedure.
 
The key word in that sentence is "if," because if the orthopedist doesn't confirm a diagnosis, you should still report the signs and symptoms.
 
Suppose a painter falls from a ladder and complains of wrist pain. The physician documents that the patient has pain on range of motion and tenderness over the anatomic snuff box, but normal X-rays. The physician documents a diagnosis of "rule out scaphoid fracture."
 
ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. You still have the wrist pain, however, which you should report as the diagnosis because no more definitive diagnosis exists.
 
In addition to the primary diagnosis (719.43, Pain in joint; forearm), you should also assign E881.0 (Fall on or from ladders or scaffolding; fall from ladder) as a secondary diagnosis to describe how the injury occurred, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director of the CRN Institute, an online coding certification training center.

Myth #3: Fudging that fifth digit is OK. If you perform a Synvisc injection to a patient's arthritic knee and another Synvisc injection to her arthritic shoulder, Medicare will only reimburse you for the knee injection. This medication (J7320, Hylan G-F 20, 16 mg, for intra-articular injection) is only payable for patients with osteoarthritis of the knee (715.16, 715.26, 715.36 and 715.96) and, therefore, that fifth-digit designation of "6" is crucial (it denotes the knee).
 
But some practices might be tempted to "creatively code" by altering the fifth digit that denotes the patient's shoulder arthritis (715.91). They report two units of the injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) but submit the claim with 715.96 as the sole diagnosis code.
 
These practices defend their actions by suggesting that the knee was addressed, so withholding the shoulder diagnosis is not lying.
 
If you report a second unit of the injection and withhold the shoulder diagnosis, you are billing fraudulently because your carrier would reimburse the second injection based on your knee diagnosis.

Truncated Diagnosis Codes Cause Denials

If you administer a Synvisc injection to a patient's shoulder, you should ask the patient to sign an advance beneficiary notice ahead of time to demonstrate that Medicare will deny the claim. This is the correct way to code visits specifically for Synvisc injections to the shoulders.
 
And don't bother reporting 715.9 alone to try to collect payment for both Synvisc injections. Your carrier will reject the entire claim based on a "truncated" diagnosis code.