Orthopedic Coding Alert

Orthopedic practices will finally be able to specify muscle weakness diagnoses, thanks to a new ICD-9 code that takes effect Oct. 1. CMS unveiled the new diagnosis codes in the May 19, 2003, Federal Register, revealing several new diagnosis codes that will affect orthopedic practices.

Welcome, 728.87!

 
Now, if a patient presents to your practice complaining of muscle weakness, your only choice is to report the unspecified code, 728.9 (Unspecified disorder of muscle, ligament, and fascia). Beginning in October, however, orthopedists should instead assign the new code 728.87 (Muscle weakness), which more accurately describes the patients condition.
 
Most physicians are unsure of what unspecified codes such as 728.9 include, says Mary J. Brown, CPC, CMA, orthopedic coding specialist at OrthoWest PC, a seven-physician practice in Omaha, Neb. More descriptive ICD-9 codes like 728.87 help paint a picture for your insurer, and that can save time by staving off unnecessary denials and appeals.
 
Not only do physicians and insurers moan when faced with unspecified codes, but coders dismay even more, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
Most coders prefer not to use unspecified codes unless there are no other options, Hammer says, but, because muscle weakness is a fairly common diagnosis in geriatric populations and postsurgical rehabilitation patients, practices had no other choice than to report 728.9.

But CMS has not deleted 728.9, and practices should still assign it for other muscle, ligament and fascia conditions that the more specific ICD-9 codes do not already describe.
 
Practices might also use 728.87 in situations when they formerly reported 780.79 (Other malaise and fatigue), Hammer says. Reporting 780.79 was definitely not a great fit when treating generalized muscle weakness. The addition of 728.87 will help you clearly document the need for inpatient stays and compliantly coding the signs and symptoms in an outpatient setting before the physician determines a firm diagnosis.

V64.43 Describes Converted Surgeries

 
CMS also introduced V64.43 (Arthroscopic surgical procedure converted to open procedure), but this new code may not pack as much punch as some practices expect, Brown says. If an arthroscopic procedure is converted to an open procedure, you should only report the open procedure, so the conversion diagnosis code probably wont be exceedingly useful, she says.
 
Its possible that this new code might apply if you perform an arthroscopic procedure, and then convert it to an open procedure for a separately identifiable condition in the same site, Brown says.
 
For example, suppose the surgeon performs an arthroscopic decompression of the subacromial space (29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release), during which she discovers a torn rotator cuff. She decides to repair the rotator cuff tear during an open procedure.
 
According to the American Academy of Orthopaedic Surgeons (AAOS) Complete Global Service Data, you should report both the rotator cuff repair code (23410-23412) and the arthroscopic shoulder decompression code (29826-51, Multiple procedures).
 
You should link the diagnosis that warranted the decompression to 29826, and link the rotator cuff tear (840.4) to 23410-23412. Its possible that carriers might recommend using V64.43 as a secondary diagnosis following the decompression ICD-9 code to demonstrate that you converted the procedure from arthroscopic to open. CMS has not yet published policies recommending guidelines for this new code, but carriers will most likely issue guidance before Oct. 1.

Abbreviate the Code for Difficulty Walking

 
If you report 719.7 (Difficulty in walking) today without adding a fifth digit to describe the site, your carrier will most likely deny the claim for a truncated diagnosis code. ICD-9 2003 now dictates that this code is invalid without a fifth digit. But in 2004, that will no longer be the case.
 
Effective Oct. 1, 2003, CMS will delete codes 719.70 and 719.75-719.79, and replace them with the four-digit code 719.7, still described as difficulty in walking.
 
The new code is a bit less specific because it no longer includes the site specifications, but it will be useful for those patients who only suffer from difficulty walking (for instance, due to neurological problems) and not because of specific joint conditions, Brown says.
 
If your patient has specific joint pain, however, you should bypass the new code 719.7 and continue to report the 719.4x series, which specifies pain in joint, Ham-mer says.

 
CMS introduced three new diagnosis codes to describe internal fixation device encounters:
   V54.01 Encounter for removal of internal fixation device
  V54.02 Encounter for lengthening/adjustment of growth rod
   V54.09 Other aftercare involving internal fixation device.

 
These new diagnoses will help us more accurately assign codes to patients with pins, plates, screws and rods, Brown says, and will replace what we previously reported with V54.0 (Aftercare involving removal of fracture plate or other internal fixation device), which CMS deletes for 2004.
 
Brown reminds coders to confirm whether their insurers accept V codes as primary diagnoses. In addition, you may need to add a second diagnosis code to fully describe the procedure in question. For example, if the orthopedist removes a patients pins following a craniectomy, you should report V54.01 and V58.72 (Aftercare following surgery of the nervous system, NEC) starting Oct. 1.

Revamp Your Concussion Codes

 
CMS deleted the general code 850.1 (Concussion; with brief loss of consciousness) and replaced it with the more specific codes 850.11 (Concussion; with loss of consciousness of 30 minutes or less) and 850.12 (Concussion; with loss of consciousness from 31 to 59 minutes) effective Oct. 1.
 
Revisions and additions to the ICD-9 manual take effect Oct. 1, 2003, and last through Sept. 30, 2004. But because many payers will wait until Jan. 1, 2004, before processing claims with the new codes, be sure to ask your payers when they will begin accepting them. CMS intends to publish an addendum to the ICD-9 changes within the next three weeks. Look for an update in the August issue of Orthopedic Coding Alert to find out whether any of the information in the addendum affects orthopedic practices.