Orthopedic Coding Alert

Watch out: Multiple providers sometimes necessitate modifiers.

You can sail through coding for trauma cases -- and get your claim submitted first, if you follow these insider tips.

Although reports and information must arrive in the coding department before coding can begin, time is critical in trauma cases due to third party liability. There are cases of first claim in is first -- and sometimes the only -- claim paid. To expedite

the filing process, you must ensure that there are policies or protocols in place to take care of these issues. Don't forget: Accuracy with the information is critical.

The coding of orthopedic trauma involves many systems. First, coders must have accurate, complete, and detailed information in the operative report. Otherwise, charges will be lost. Therefore, physician documentation is critical. What to do:

Educate your physicians about the details you need. Ensure that each anatomical site is clearly identifiable in the report and that each injury is well documented.

Pitfalls: Many times people create reports with documentation that runs together and there is no clear indication as to where one wound ends and another begins. In addition, sometimes so much emphasis is placed on the "primary" injury that

incidental injuries become lost in the haze of poor documentation. Often, there are codes in the integumentary system that never make their way into the claims. Remember: You should never code from the "procedure line."

As orthopedic coders, we are all familiar with the debridement codes 11010-11012. These codes represent the debridement associated with fractures. CPT Assistant (March 1997) states the following: "They [11010-11012] are intended to address

treatment of a number of injuries that require extensive preparation in order to adequately repair a wound site, including both open and closed fractures, and usually involve numerous layers of flesh and bone." The article goes on to say, "Some

closed fractures may have associated skin contusions, deep abrasions, burns, and cutis separation from subcutaneous tissues (separation of the skin layers), [and] may require fracture debridement."

Watch out: Payers may be reluctant to pay 11010-11012 for closed fractures. The above excerpt supports the coding of a closed fracture debridement. Again, your ability to collect depends on the documentation. The additional work must be

evident in the documentation and the additional procedure must be medically necessary.

Wound debridements (11041-11044) are often miscoded or undercoded. The physician may mention the debridement but not document well enough the debridement's depth or its specific location.

Action: In these cases, you have only two options: 1. Hold the claim until you can clarify the procedure with the provider.

2. Code the lowest level of debridement.

Doctors- offices also often overlook coding for the initial cleansing and dressing of burns. Look for "road rash," which can be a significant and very painful injury -- a form of friction burn.

Preparing a wound for skin grafts and complicated closures is another area that is missed. The AAOS Global Service Data states, "Complicated closures are separately paid."

Catch: The coder, however, must be able to identify the additional work involved that would support a complex closure in addition to the primary procedure. Terms that may indicate this are "undermining," "preparation of flaps," "retention sutures,"

and "rubber bolsters."

Use modifier 59 (Distinct procedural service) to indicate the procedure is distinct and should be separately paid. A "normal" closure is part of the primary procedure. For multiple wounds and repairs unassociated with the primary procedure,

modifier 59 may be required to indicate a separate anatomical site. Check the Correct Coding Initiative (CCI) to see if the codes are bundled and the edits allow a modifier 59.

Use anatomical modifiers when appropriate. Modifiers TA-T9 (toe), FA-F9 (finger), RT (Right side), and LT (Left side) prevent the overuse of modifier 59 and provide specificity to the payer.

If the surgeon has to take the patient back to the operating room for debridement, you would use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) for "staged" or "anticipated." The

documentation determines the "type" of debridement. Do not confuse modifier 58 with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative

period), which is a return to the OR for a related "procedure."

Because each injury, anatomical site, and provider has the potential for additional codes, you must identify each injury. Tip: For complex cases, I find it easier to work with a hard copy and underline every location, injury, and provider. Identify

every procedure performed with a CPT code and associate the diagnosis code with it. Review for bundling issues once you have completed the process.

Debridements of open fractures are always coded separately, as well as application of external fixation systems. Review CPT Assistant for guidance in coding debridement codes with a closed, severely deranged fracture. Remember modifier 59 is

never appended to the primary code or coded with modifier 51 (Multiple procedures). Also, if the anatomical modifiers are better choices, select them instead of modifier 59.

When the same physician is the only provider performing multiple services, identify all procedures, great and small. Check the CCI edits for bundling issues.

Rank the procedures in descending order starting with the code that has the highest relative value unit (RVU) per Medicare or allowed amount for private payers. Medicare's multiple procedure fee reduction applies to all subsequent codes unless

they are add-on codes or exempt from the principle. If indicated in the Medicare Fee Schedule Data Base (MFSDB) field 21 with an indicator "2," payment is made at 100 percent for the first procedure and 50 percent for the second through the

fifth. Beyond five codes, Medicare will pay based on review. Other payers may have different rules so you need to know their rules for multiple procedure reimbursement.

For claims involving multiple providers performing multiple procedures, identify each provider, his or her specialty and associated group, and his or her role in the case. If Dr. B is unrelated to your specialty or group and is working independently

(reporting separate codes), Dr. B will bill his codes independently with no modifier. Your physician will also bill his codes with no modifier.

When multiple physicians of different specialties work together, identify all providers and their specialties. Next, identify each procedure and who is performing what in each surgical wound. This statement from the Medicare Carriers Manual

simplifies our coding a great deal: "If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same

incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services" (100-4-12-40.8 section D). Normally in cases so severe as to require multiple surgeons, the surgeons will be of different

specialties and their procedures are related to a separate diagnosis; however this is not necessarily the case. But if they are of the same group specialty, the only options are to bill the codes with modifier 80 (Assistant surgeon), 62 (Two

surgeons), or 51 depending on the work.

Codes allowed for team surgery are also indicated in the MFSDB in field 25. Compared to the number of codes we have, there are only a few, including kyphectomy codes 22818-22819, arthroplasty codes 22862 and 22865, and vertebral

corpectomy codes 63081-+63091.

All other procedures performed with multiple providers of different specialties will be billed independently by each provider. Team surgery is paid based on the report. Each surgeon would bill the same procedure code with modifier 66 (Surgical

team). Remember payers may have different rules.

If Dr. A and Dr. B of the same group practice perform procedures in the same session on separate anatomical sites, first bill the highest valued procedure and bill the lower, subsequent procedure with modifier 51. Treat the session as though

one provider performed the procedures regardless of the number of procedures.

If Dr. C performs a portion of the procedure that Dr. A is performing, both would bill the same code with modifier 62. Suppose Dr. C is a plastic surgeon who performs the exposure and closure and Dr. A performs the definitive procedure. The

exposure and closure is included in the definitive procedure's RVUs. Therefore, both physicians are performing a "part" of the procedure. The MFSDB indicates in field 24 the procedures that allow payment for modifier 62 (If two surgeons, each in

a different specialty, are required to perform a specific procedure, each surgeon bills for the procedure with a modifier "-62."). This will require communication between the two providers because each claim must be the same.

If Dr. B assists Dr. A in the procedure to expedite the process, use modifier 80. If Dr. A has a physician assistant (PA) or a physician assistant certified (PA-C) assist him, modifier AS (Physician assistant, nurse practitioner, or clinical nurse

specialist services for assistant at surgery) is appended to the assistant's claim instead of modifier 80. Modifier 80 is indicative of a physician performing the assistance. The MFSDB lists all codes that allow payment for an assistant at surgery.

Severe trauma cases are far removed from "normal." Code according to the documentation and send to the payer for review with a letter outlining why the claim should be paid. This is not fraudulent; you are giving them the opportunity to pay or

decline based on the information provided. There are times when it is appropriate to be "outside the box." Just make sure the documentation supports you claim.

Guest columnist Quita W. Edwards, CCS-P, CPC-Ortho, CPC-I, is a coding and reimbursement specialist with Forsyth Street Orthopaedic Surgery and Rehabilitation Centers in Macon, Ga.