Orthopedic Coding Alert

Because coders are often unable to find definitive guidelines for determining which conditions are acute and which are chronic, your practice should create internal guidance to help decide how to categorize certain injuries and conditions in the absence of local carrier direction.

The acute versus chronic decision is important for many reasons. For instance, some state health information regulations require an E code as the secondary diagnosis when acute injuries are reported, and certain drugs are approved only for acute or chronic conditions.

In addition, a patient encounter may qualify for a higher-level E/M code when the orthopedist treats several chronic conditions during the same visit. For instance, a low level of risk (often reported with level-three codes 99203 or 99213) in the E/M medical decision-making (MDM) guidelines includes exams during which the orthopedist treats one stable chronic illness, whereas a moderate level of MDM (relating to level-four codes 99204 and 99214) involves treating two or more stable chronic illnesses.

This can put intense pressure on orthopedic practices that can't always categorize patients' injuries and conditions. For example, a patient suffers a rotator cuff strain (840.4) while lifting boxes at work. The patient's workers' compensation carrier reimburses the practice for several months, after which the orthopedist decides that the patient requires surgery to repair what the physician determines is actually a torn rotator cuff (727.61). At this point, the workers' compensation insurer balks, stating that the claim will not be paid because it never authorized treatment for a torn rotator cuff. Can't the practice upgrade a patient from an acute condition to a chronic one?

That depends on the insurance company, says Jacqui Jones, office manager at Klamath Orthopedic and Sports Medicine Clinic in Klamath Falls, Ore. Acute conditions, such as rotator cuff strains, are often treated conservatively and respond well with no further treatment. Sometimes, however, the conservative treatment fails, she notes, and the patient requires surgery after all, at which point the condition would be upgraded to a chronic one. "This could take as long as a year," Jones says.

Jones recommends listing the patient's current condition the complete rotator cuff rupture (727.61) as the primary diagnosis. Coders should assign 905.7 (Late effect of sprain and strain without mention of tendon injury) as the secondary code to help create a connection between the two conditions.

Many practices designate a three-month period for a condition to remain acute, after which it becomes chronic. This time period varies widely, however, with some practices allowing only a few days before "acute pain" turns chronic, while others give the patient six months or more.

Although CMS does not officially comment on how to differentiate between acute and chronic conditions, there are certain instances when Medicare defines the terms. For example, in a July 23 decision memorandum announcing coverage of electrical stimulation for chronic wounds, CMS defines a chronic wound as persisting for "longer than one month."

Orthopedic practices should set general guidelines for determining when acute conditions become chronic, based on their most common diagnoses. Orthopedists should review patient medical records to determine an average period of when each type of injury heals or requires surgery and create a list of those averages as a guideline.

Even if your practice's policy is based on a three-month acute period, however, that won't necessarily be the case with every patient. Some patients may show marked improvement after three months, and the orthopedist will want to continue listing the condition as acute for three more months. Some patients' conditions will worsen after one month, causing an upgrade to "chronic." According to Laureen Jandroep, OTR, CPC, CCS-P CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J., time will not always be the deciding factor.

"I view it more as ongoing versus flare-up," Jandroep says. For instance, a patient might have carpal tunnel syndrome (354.0) for a year, but a sudden flare-up might cause such severe pain that a carpal tunnel release (64721) is necessary.

According to Medline's medical encyclopedia, "Acute conditions are severe and sudden in onset" (e.g., a broken bone). "A chronic condition, by contrast, is a long-developing syndrome, such as osteoporosis." It notes that osteoporosis (a chronic condition) may cause a broken bone (an acute condition). In this case, both diagnoses would be reported, with the broken bone (733.1x) listed first, followed by the underlying disease (733.0x, which is the code for osteoporosis).

Section 1.4 of the American Hospital Association's Official Inpatient and Outpatient Coding Rules advises, "If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first."