Orthopedic Coding Alert

Upgrading a rotator cuff strain to a torn rotator cuff can land your claim in troubled waters, especially as local carrier direction can be nonexistent. If your insurance adjuster lacks specific chronic/acute advice, create your own internal guidelines -- our experts show you how.

Scenario: Suppose 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 your practice upgrade a patient from an acute condition to a chronic one? Here's our experts' breakdown.

In the example above, you have a dispute from workers' compensation, because the physician diagnosed the patient with a rotator cuff strain (840.4) and now determines that the patient has a torn rotator cuff (727.61). "Your practice can't upgrade a condition without calling or getting authorization from the workers' compensation company," says Lenise Chiriboga, CPC, workers' compensation and collection department coder for Premier Orthopaedics & Sports Medicine in Teaneck, N.J. "You or your doctor can ring the case manager or adjuster."

Jacqui Jones, office manager at an orthopedic practice in Klamath Falls, Ore., seconds that advice. "The U.S. Department of Labor (the workers' comp carrier for federal employees) requires any change to go through its claims adjuster," she says.

"The adjuster has to authorize the new ICD-9 code and then notifies their outsourced claims procession company that the new code is good."

Changing the diagnosis really depends on the carrier, but "it truly is the doctor's call, and ultimately, the insurance should recognize the change -- as long as it is related to the original injury," she says.

What to say: Acute conditions, such as rotator cuff strains, are often treated conservatively and respond well with no further treatment. Sometimes, however, the conservative treatment fails, Jones 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," she says.

Jones recommends listing the patient' s current condition -- the complete rotator cuff rupture (727.61) -- as the primary diagnosis. You 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.

Suppose your worker's compensation carrier doesn't have specific guidelines about chronic versus acute conditions and what to do when you need to upgrade.

Good idea: 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, Medicare does define these terms in certain instances. For  example, CMS defines a chronic wound as persisting for "longer than one month."

Action: Use your most common diagnoses as a basis for setting timeframes in your acute/chronic guidelines. How: Review your patient medical records to determine an average period when each type of injury heals or requires surgery. Create a list of those averages as a guideline.

Keep in mind: 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." Time will not always be the deciding factor, says Laureen Jandroep, OTR, CPC, CPC-H, CPCEMS, coding analyst for CodeRyte and senior instructor for codingcertification.org.

"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, Neuroplasty and/or transposition; median nerve at carpal tunnel) is necessary. Note: ICD-9's official guidelines state, "If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indention level, code both and sequence the acute (subacute) code first."

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 longdeveloping syndrome, such as osteoporosis." It notes that osteoporosis (a chronic condition) may cause a broken bone (an acute condition). In this case, you would report both diagnoses, with the broken bone (733.1x) listed first, followed by the underlying disease (733.0x, which is the code for osteoporosis).