Orthopedic Coding Alert

Baseball season has arrived, which means orthopedists should expect to see a sudden increase in elbow ligament injuries. You can stay out of left field by assigning a ligament reconstruction code (24344, 24346) if the orthopedist performs a graft, and a repair code (24343, 24345) if the patient suffered an acute tear requiring no graft.

Baseball fans are all too familiar with torn medial (841.1) and lateral (841.0) collateral ligament injuries, which have sidelined such famous major-league pitchers as John Franco and John Smoltz. But these injuries can affect amateur players and even those "weekend warriors" who don't warm up appropriately before picking up the baseball or basketball. If conservative therapies fail, orthopedists usually perform either a ligament repair or reconstruction, depending on the breadth of the injury, and each surgery poses its own coding challenges.

Grafts Signal Reconstruction

Because orthopedists don't always use the words "reconstruction" or "repair" in their operative reports, coders may have difficulty choosing from the following elbow ligament surgery codes:

"The main key word to look for when distinguishing between repair and reconstruction is 'graft,'" says Nancy L. Williams, CMA, CPC, coding specialist at the Center for Sports Medicine and Orthopaedics in Chattanooga, Tenn. "If the orthopedist documents a graft, then you know he has performed a reconstruction rather than just repairing the local tissue." If the physician does not document a graft, he or she probably performed a repair.

In addition, the patient's diagnosis can provide essential clues. "While orthopedists could perform a reconstruction on an acute tear, they most often use reconstruction on patients with chronic tears," Williams says. If the orthopedist documents a chronic tear, therefore, he or she probably reconstructed the ligament.

To distinguish between lateral (24344) and medial (24346) collateral ligament reconstruction, you should note that the lateral collateral ligament attaches the humerus to the radius, while the medial collateral ligament attaches the humerus to the ulna.

Orthopedists often document abbreviations instead of the full anatomical ligament name. If the orthopedist documents a torn "RCL," "radial collateral ligament" or "LCL," he or she is referring to a torn lateral collateral ligament.

Likewise, physicians often refer to the medial collateral ligament as the "MCL," "ulnar collateral ligament" or "UCL." Therefore, you would probably assign 24346 if the surgeon documents a chronic tear to the UCL, or if he or she documents a "Tommy John" surgery another nickname for UCLreconstruction.

"The orthopedist most often performs grafts from the palmaris longus tendon during reconstruction," Williams says. "The graft harvest is included in the reconstruction codes, so you should not charge a graft harvest separately."

Team Trainers Can Request Consults

Determining whether you should report a consultation (99241-99245) or a new patient office visit (99201-99205) code can be difficult even in the most straightforward cases. And when a nonphysician practitioner sends a patient your way, this determination can become even more daunting.

Suppose a college baseball pitcher suffers an elbow injury. The team athletic trainer requests your orthopedist's opinion regarding the patient's diagnosis and asks you to submit a written report to him so he can determine whether the patient should continue to play. The orthopedist diagnoses a torn medial collateral ligament in the patient's right elbow and issues a report to the team athletic trainer. Does the orthopedist report a consult (99241-99245) or a new patient office visit (99201-99205) because a trainer not a physician requested the orthopedist's opinion?

CPT dictates that a consult can be requested by a physician "or other appropriate source." Although CPT doesn't define "other appropriate source," most insurers allow a variety of caregivers to request consultations. Ask your carrier which healthcare professionals it deems "appropriate."

According to the August 1997 issue of CPT Assistant, "From a CPT coding perspective, CPT guidelines do not set restrictions regarding individuals who may be considered an 'other appropriate source.'Some common examples may include a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language therapist, psychologist, social worker, or lawyer."

The example above is a clear-cut consultation, and you should report 99241-99245 for it, depending on the complexity of the visit.