Orthopedic Coding Alert

Watch out: Even documented procedures aren't always billable

Proper coding often depends on knowing what to report. But knowing what not to report can be just as important.
 
For instance, standard of care and bundling guidelines (whether imposed by CPT, CMS or third-party payers) often limit which procedures you can claim separately. To be certain that you are capturing all the reimbursement your physician deserves without overcoding, first list all the identifiable procedures in the documentation and then go back and look for bundles.

Check Out the Op Report

To test your skills, consider how you would code this sample surgical note. Then read on to see how you fare:

Preoperative diagnosis: Left closed intertrochanteric femur fracture.

Postoperative diagnosis: Left closed intertrochanteric femur fracture.

Procedure: Open reduction left intertrochanteric femur fracture with dynamic hip screw and four-hole plate.

Procedure justification: 25-year-old male involved in vehicle collision in May 2005. The patient sustained a fracture and dislocation of C7 and T1 with a complete spinal cord injury. The patient at that time also sustained a closed intertrochanteric femur fracture. Initial plan was to manage patient nonoperatively, but follow-up showed nonunion of left intertrochanteric femur fracture. Therefore, scheduled open reduction, internal fixation of injury in July 2005.

Procedure: Fluoroscopy was brought into the room, and under direct visualization, we properly positioned patient so that the fracture was in the best alignment - Using the fluoroscopy, the level of the greater trochanter was verified - a longitudinal skin incision was made - the subcutaneous tissue and muscle were also sharply dissected down to the level of the proximal femur - care was taken to remove all the excess callus that had formed - this caused significant bleeding [that was] monitored by the operative surgeon and the anesthesiologist.
 
- Care was taken to achieve the proper alignment - Once alignment had been achieved, the appropriate-size plate was selected - large clamps [were used] to maintain the reduction and hold the plate. [The plate was secured] under direct fluoroscopy - it was found that the patient would benefit from a 90-mm screw to be placed in the proximal screw hole - Again fluoroscopy [was used] - the remainder of the distal four holes were appropriately filled.
 
The wound was copiously irrigated with large amounts of saline - closure [was achieved] - and the patient was removed from the fracture table.

How would you code this note?
 A. 27244, 76000-26, 20650-59
 B. 27244-22, 76000
 C. 27248, 76000-26
 D. 27244.

Consider All Possibilities

 If you scan the op report, you can identify the following procedures and services:

 - Use of fluoroscopy
 - Incision and approach
 - Site preparation
 - Control of bleeding
 - Fracture reduction
 - Placement and securing of plate
 - Closure.

The primary procedure in this case is the open reduction of the left intertrochanteric femur fracture with placement of a plate. The best choice in this case is 27244 (Treatment of intertrochanteric, peritrochanteric or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage), says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. The op note clearly describes open treatment of intertrochanteric fracture, rather than a greater trochanteric fracture as described by 27248 (Open treatment of greater trochanteric fracture, with or without internal or external fixation).
 
Code choice so far: 27244.

 -The approach, site preparation and closure are included in the surgical fee for the primary procedure,- says Suzan Hvizdash, CPC, physician educator for the UPMC Department of Surgery in Pittsburgh and a former American Academy of Professional Coders national advisory board member. -You shouldn't code separately for these items.-
 
Code choice so far: 27244.

The op note also describes extensive use of fluoroscopic guidance (76000, Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]). However, Medicare limitations mean that you won't report 76000 separately, either with or without modifier 26 (Professional component).
 
-The correct coding initiative [CCI] bundles fluoroscopy into 27244 [the primary procedure], so I would not report 76000,- Stout says.
 
Code choice so far: 27244.
 
What about control of bleeding? When the physician performs a major procedure, control of bleeding is an included component of the surgery. Typically, the only way a physician can gain separate reimbursement for control of bleeding is if it is the only procedure he performs.
 
If, however, the physician performs significant extra work to control bleeding during a major procedure, you may attempt to collect additional reimbursement by appending modifier 22 (Unusual procedural services). Just be sure that the documentation is bulletproof. Keep in mind that you cannot use modifier 22 if your surgeon caused the bleeding in the first place.
 
Payers set a high bar for reimbursement with modifier 22, and unless the physician specifically states that significant additional time and/or effort was necessary -- and he is able to quantify this difference (for instance, a note stating -an additional four pints of blood were needed --) -- you are better off leaving 22 off the claim, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.
 

In this case, the documentation doesn't support using modifier 22.
 
Code choice so far: 27244.
 
Don't Make Assumptions

Whatever you do, don't assume that the physician did something he didn't document. For example, in this case you shouldn't report 20650 (Insertion of wire or pin with application of skeletal traction, including removal).
 
-I see no supporting documentation for code 20650,- Stout says. -While is it certainly possible that the surgeon placed a traction pin at the beginning of the procedure to assist in reduction of the fracture, 20650 is a designated -separate procedure- and would be considered inclusive to the major procedure.-
 
The only time that you would report 20650 separately with 27244 is if the orthopedist inserted a wire or pin for skeletal traction to treat an injury other than the left intertrochanteric femur fracture. In that case, however, you should append modifier 59 (Distinct procedural service) to 27244 to show that it is distinct from the fracture treatment and is therefore separately payable.
 
Final code choice: In this case, you should report only 27244. All other services described in the op report are included in the primary service, and no modifiers are necessary to report special circumstances.

Don't Forget the Dx
 
Every CPT code needs a diagnosis to justify it, and in this case you should describe the closed intertrochanteric femur fracture using 820.21 (Pertrochanteric fracture, closed; intertrochanteric section).
 
In addition, because the injury was the result of a motor-vehicle accident, you can also use an E code (such as E813.x, Motor vehicle traffic accident involving collision with other vehicle) to provide further detail. E codes don't affect your reimbursement, but they can facilitate payment, help determine who is responsible for payment and possibly affect legal situations down the line.
 
But remember that you should never report an E code as the primary or only diagnosis code. You must include a standard ICD-9 code to indicate the patient's condition. E codes are only a supplement to your claim, not the main event.