Orthopedic Coding Alert

New coders soon learn that there is more to coding than merely selecting an appropriate number from the ICD-9 or CPT manuals. They quickly come face-to-face with a series of obstacles that perhaps no one in their training courses has shared.

Collectors in the office may introduce these obstacles when a payer denies a claim for "medical necessity." Whatever way it happens, coders learn quickly that there are various tools that need to be included in their "coding toolbox."

Two important coding tools include the knowledge of payer coverage policies and payer reimbursement polices. Understanding how to use these different policies can turn an average coder into a valuable resource for the provider. Here are the details.

Coverage policies, also known as medical polices, detail various procedures that carriers have determined to be "misunderstood" or potentially abused. These policies include carriers- research into clinical information from medical societies regarding what the procedure is for and how it's done.

The policies also list the applicable CPT codes for the services along with ICD-9 codes that indicate medical necessity. Unless the submitted service in the article has a linked diagnosis from the policy, the carrier will likely deny the claim. Under certain circumstances, you can appeal a denied claim with other information and documentation. On the other hand, the likelihood of overturning a denial based on medical necessity will depend on carrier rules and interpretation of the procedure performed, and the payer will measure your procedure's necessity against the coverage policy.

CMS has a number of these policies called NCDs or national coverage determinations. These polices are often interpreted, cited and referred to by the regional Medicare offices (carriers and fiscal intermediaries) and serve as the basis of the LMRP (local medical review policy) now known as the LCD (local coverage determination). You can find these both on the CMS Web site under NCD or on the local or state Medicare Web site under the LCD.

You can find an example of an NCD policy (for osteogenic stimulators for bone regeneration to aid in bone fracture healing) here: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=150.2&ncd_version=2&basket=ncd%3A150%2E2%3A2%3AOsteogenic+Stimulators.

Insurance carriers like Aetna, Blue Cross, UnitedHealthcare, Cigna and Humana also have coverage determinations for some procedures, and you can find these on their respective Web sites.

Unfortunately, however, some carriers require that you obtain a password before they allow you to view the policies. But over the years, carriers have become more open about their edits and medical policies.

Important: As a side note, sometimes payer contracts and patient coverage plans will have special carve-outs to include special codes or to deny certain procedures. In those instances, the contracts take precedence over general payer policies.

An example of a coverage policy can be found on the UnitedHealthcare Web site, www.unitedhealthcare- online.com, under Policies and Protocols where the Medical Policies are located.

Orthopedic coders should to be aware that there are medical-necessity guidelines for arthroscopic debridement and lavage of the knee joint for osteoarthritis and also for metal-on-metal or ceramic-on-ceramic hip prosthetic for total hip replacement and revision. Aetna has quite a number of policies that affect the orthopedic coder as well, and you would benefit from being aware of these policies and how to use them.

The other kind of policy to know about is the "Reimbursement Policy," which is similar to the medical or coverage policy. The reimbursement policy details how various payers want you to use the codes and modifiers.

An example of this is the often-misunderstood bilateral modifier 50 (Bilateral procedure). By description, CPT tells us that when we code a procedure with modifier 50, the provider performs the (same) procedure on both the right side and left side of the body.

Some payers differ in the way they want you to report this on the claim. There are some who want a single line item (CPT code on one line) with modifier 50, with a single unit. Others, such as Physicians Health Plan (PHP), want a single line item with modifier 50, with two units. Still others want a single line item without a modifier with a single unit, then on the second line item, the same CPT code with modifier 50 with a single unit. These differences are due to the limitations of the processing capabilities of different claims adjudication software.

Other payers, such as some local Medicare offices, spell out the bilateral procedure as the same procedure (with the same CPT code) performed on opposite sides of the body. For example, Medicare may want you to code a right hip injection and a left hip injection as 20610-50 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) x 1.

If the injection happened in the right knee and the left shoulder, however, you would report 20610-RT and 20610-LT to indicate the same procedure but on two different sides of the body and not necessarily the same body part.

Ultimately, coders are responsible for knowing the payer guidelines on this and many other reimbursement policies so that they can properly report the appropriate procedures performed using the correct codes and modifiers.

Some providers will write on a superbill a series of procedures that they have performed and will do the same with a series of diagnoses. The coder then must link the correct diagnosis codes with the procedures.

Referring to a coverage policy can help determine which diagnosis code is appropriate for a particular procedure. On the other hand, picking and choosing a diagnosis that is covered by an LCD or payer coverage policy if the provider hasn't supplied one is not the coder's responsibility. Coders need to realize that the final responsibility for knowing and understanding the coverage policies falls to the service provider. Although coders may report the medical events, the coder is neither a clinician nor a physician and is not allowed to guess or infer the provider's intent when the information given isn't clear.

As advancements and techniques in science and medicine progress quickly, there are times when a provider will learn about various procedures and will hear various reasons for why a particular procedure is performed.

The coverage and medical policies for that procedure, however, may not have progressed as quickly. Providers are often quick to assume that because the advancements suggest rapid change in technique and reasons for doing the procedures, there is medical justification for doing those procedures.

Although medical justification or necessity may exist for doing a procedure, those same medical advancements in technique and necessity might not have progressed as quickly with carriers that have pre-established coverage and medical policies. Payers may deny claims when the diagnoses reported don't match the coverage policy criteria.

Take action: A wise coder who understands how all of these elements work together can help the provider develop a good communications strategy with the various insurance companies. If you gather documents, resources and medical society information regarding the new techniques, procedures and illnesses treated, sometimes denials based on a medical policy can be overturned when appealed. Coders can also help carrier representatives update and create new policies based on the new information that the provider has learned.

Policy updates, unfortunately, don't happen simultaneously, but with an open and proactive dialogue, denials can be overturned and new policies can be created or changed so that future claims don't hit those edits that get negative results. Providers don't have to feel completely frustrated and powerless as if the insurance carriers are totally in control by determining the standard of care and practicing medicine. Coders who have this information in their "coding toolbox" can be a valuable resource to their company and/or provider.

-- Leslie Johnson, CPC, is a coding and compliance consultant and education and research director for DR Management in Indiana. Orthopedics is one of her many coding specialties. She is also founder of AskLeslie.net.