Orthopedic Coding Alert

When searching for a diagnosis code to list on a claim when no definitive ICD-9 code exists, orthopedic practices can prevent denials by using the patient's symptoms rather than guessing at a code that seems "close" to the patient's condition.

Every orthopedic coder encounters this situation: The orthopedist lists a diagnosis on the patient's chart, but no ICD-9 code exists for that condition. Although a common cure for this problem is to find a condition similar to your patient's diagnosis and hope the claim processes without delay, this is not correct coding. If the patient's diagnosis is truly unlisted, you should use either the code describing the patient's symptoms or an "other disorders" code.

"One of our orthopedists gave me an operative report with a diagnosis of internal torsion of the tibia," says Danielle Caldwell, billing and coding supervisor at Orthopedic Associates in Pittsburgh. "There is no code listed for it, so we used 736.89 [Acquired deformities of other parts of limbs, other]. We were paid for it without a problem."

Although this code's descriptor does not specifically state "internal torsion of the tibia," its use is appropriate, because "torsion, tibia" in the ICD-9 manual's alphabetical listing refers coders to 736.89. It is also much more accurate than guessing at a code that the coder believes might be "close" to the patient's condition.

Only the physician should choose a diagnosis code, and even the orthopedist should not attempt to code a condition "close" to what the patient has. If an accurate code doesn't exist, go to the Symptoms, Signs, and Ill-Defined Conditions section of ICD-9 (780-799.9, see text box on page 53) and find something that does. If you cannot find a code based on the information a physician provides, you are obligated to go back to the physician and say, for example, "I can't find a code for internal tibial torsion is there another name for it?"

When lacking a specific diagnosis, use the codes for the symptoms that brought the patient to the office. Do not use a suspected diagnosis. For instance, suppose a patient presents with leg pain and a bowed femur, and the orthopedist suspects Paget's disease. He examines the patient and requests an additional visit to perform further testing. The claim for the patient's E/M visit should be submitted with the codes for leg pain (729.5, Pain in limb) and bowed femur (736.42, Genu varum [acquired]), not Paget's disease (731.0).

The Official ICD-9-CM Guidelines for Coding and Reporting, developed by the Public Health Service and CMS, says, "Do not code diagnoses documented as 'probable, 'suspected,' 'questionable,' 'rule out,' or working diagnoses. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit."

In some situations, using the codes for the patient's symptoms not only provides more accurate coding but also avoids inappropriately labeling the patient, which can have long-term consequences. "If a patient is assigned a code for a disease he or she does not have, it could affect their ability to get life or disability insurance," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.

For instance, suppose the practice submits the claim to Medicare with the ICD-9 code for Paget's disease. Tests later show that the patient does not have Paget's disease. "Several years later, the patient applies for life insurance and is quoted astronomical rates and can't figure out why," Jandroep says. What the patient doesn't know is that the insurance company got records from the physician's office and sees that she was listed as having Paget's disease.