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 fracture, you should not report 820.21 (Pertrochanteric fracture, closed; intertrochanteric section) for the visit one year after the patient's hip healed. Instead, you should report V54.13 (Aftercare for healing traumatic fracture of hip).

In other words, if the hip fracture is no longer an acute condition (that is, the fracture has healed following physician care), you are incorrect to use the fracture as a primary diagnosis.

Pitfall: Coders and physicians often make the mistake of overlooking V codes for a patient whose disease process is no longer active, says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla.

According to the ICD-9-CM Official Guidelines for Coding and Reporting, -Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.-

Therefore, you can report these V codes as your primary diagnoses when the physician must see the patient for continued care due to his previous condition or ongoing disease.
 
Use Treating Diagnosis for PT

Snag 3: You just hired a physical therapist, and your surgical coder is coding all of the PT's services. She noticed that very few of the PT policies list as -payable- the diagnosis codes that the surgeon and PT are treating. Why would that be?

Solution: Physical therapists and their coders often confuse the referring physician's medical diagnosis with the therapy treatment diagnosis, and undue denials result. To solve this problem, always ask yourself this question: -What is the patient's specific condition or problem that the PT is treating with this therapy service?- You should never assume that the diagnosis on the physician's request form is the relevant diagnosis for the therapy that the PT rendered.

For example: A patient requires therapy for gait disturbance (781.2) due to osteoarthritis (715.xx). The physician's request states -evaluate and treat,- but it also lists the medical diagnosis of osteoarthritis that the physician has been treating. The PT spends 30 minutes performing gait-training exercises, so you report two units of 97116 (Therapeutic procedure, one or more areas, each 15 minutes; gait training [includes stair climbing]). Then you erroneously list osteoarthritis code 715.xx as the primary diagnosis to justify the medical necessity of the therapy.

Right way: You should report gait-disturbance code 781.2 as the specific diagnosis the PT is treating with therapy. Most payers want to see a specific -treatment diagnosis- as the primary ICD-9 code on therapy claims. If you list osteoarthritis as the primary diagnosis, chances are the carrier will deny. This explains why your local coverage determinations (LCDs) don't always list the physician's diagnosis on the PT guidelines.
 
Even if you do receive payment with an incorrect ICD-9 code, you risk problems with reimbursement down the line. Medicare, private carriers and fiscal intermediaries have physical therapy policies that list specific frequency limitations and other coverage guidelines for every diagnosis, and you may find that your patient is eligible for far less coverage than he needs if you-re reporting the wrong diagnosis.