Orthopedic Coding Alert

The guidelines spell out the requirements for aftercare, V codes

What should you do when you see a V code listed first on your orthopedic surgeon's claims? This is just one of the coding questions that you may encounter when dealing with orthopedic claims.

We-ve compiled three coding scenarios and their solutions to help you overcome these common orthopedic coding challenges. Report All Documented Diagnoses Snag 1: A surgeon dictates -Primary Diagnosis: Osteoporosis- on an op report for a vertebroplasty procedure, but later in the body of the op note, the surgeon also notes that the patient has closed fractures of the vertebrae at L1 and L2.

The coder researches the payer's policy on percutaneous vertebroplasty and finds that 733.00 (Osteoporosis, unspecified) is not a covered diagnosis for 22521 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar), but 733.13 (Pathologic fracture of vertebrae) is.

Coders are routinely taught to list the surgeon's primary diagnosis as the ICD-9 code on the claim form--can this coder use the lumbar fracture as the diagnosis on the physician's claim, or must she stick with osteoporosis?
 
Solution: -As long as it is documented, you are permitted to choose whichever diagnosis supports the procedure,- says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education LLC in Boardman, Ohio.

-You can even choose the diagnosis from the body of the op report if what's listed at the top is a non-allowed diagnosis,- she says. But it would be incorrect to use a diagnosis code that the surgeon did not document but gets the claim paid, she says.

Why would the physician list the primary diagnosis as osteoporosis, even if he performed vertebroplasty for the fracture?

-Often the doctors are not aware of the local coverage decisions, etc., so they just list the diagnoses in whatever order comes to mind,- Vogelberger says. -It's the coder's job to find the correct diagnosis to support a claim based on the medical necessity.-

Bottom line: The surgeon may list the primary diagnosis using any of the patient's conditions, but that doesn't mean you have to list that ICD-9 code on your claim. If he dictates another, payable diagnosis, you should list that instead.

In our example above, the coder should report 733.13 followed by 733.00 as her diagnoses. Go Ahead: List V Codes as Primary Diagnoses Snag 2: A patient has a traumatic hip fracture due to a fall. A year later, the patient, who is now asymptomatic, returns to the practice for routine follow-up care. Should you list the hip fracture ICD-9 code as your diagnosis for the follow-up visit, during which the surgeon performs an E/M and takes an x-ray? Solution: Because the patient no longer has a hip [...]