Orthopedic Coding Alert

Carefully read the physician's notes to extract ICD-9 codes In the perfect coding world, our physicians would support the coders- efforts by providing CPT codes for all services rendered, properly document these services, and then link their procedures to supporting ICD-9 codes. But let's have a reality check -- it rarely works like that. 

Hopefully your physicians realize the importance of coding and have taken a more active role in this function. The amount of participation is going to vary greatly, so we as coders need to be able to fill in the gaps.

The gaps may be simply checking for bundling edits and solid linkage between your procedures and diagnoses but, unfortunately, may often mean combing through lengthy office documentation and complicated procedure notes to assign all codes and diagnoses on your own. 

The provider has hired you for your coding expertise and trusts that you will do as much background work as  possible so that when you do have to seek clarification, the physician will be able to determine, due to the documentation, why you had to ask what you did.
 
This interaction allows the coder to learn and make notes so you are prepared the next time the same situation presents itself. In addition, the providers will learn where their documentation is deficient so they can then supply us with all information needed to make the process a smooth one -- from rendering the service, to having the claim go out the door quickly so they can be paid for what they are doing.  Check the Notes for Clues Let's examine some examples of situations in which  the coder must fill in the gap when the provider has not written a diagnosis on the patient's superbill. 

Example 1: The physician's superbill shows a level-three consult with a knee orthosis (L1810). It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code.

First step: We refer to the dictation, which reads: -The patient is a 13-year-old female being evaluated as a consultation at the request of Dr. Jones for left knee pain. Left knee pain started on 12-9-06 when she did splits during cheerleading.- The physician completes the remaining history, ROS, PFSH and exam.

Moving down through the chart note, we see that the patient brought an MRI with her that demonstrated a contusion of the medial femoral condyle.

Under a separate heading, the doctor has given his assessment, which states: Left medial femoral condyle contusion and MCL sprain.

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