Orthopedic Coding Alert

In orthopedic care, as in other disciplines, two schools of thought exist when it comes to evaluation and management (E/M) guidelines. Some physicians and coders swear by the 1995 Health Care Financing Administration (HCFA) guidelines for assessing the correct level of E/M service, while others see the 1997 guidelines as not only a more precise tool, but also the wave of the future for E/M coding.

An E/M History Lesson

CPT first introduced the system of coding office visits, known as E/M codes, in 1995. Prior to that, office visits were called low, moderate, intermediate and high, with very little definition to distinguish between levels. The 1995 E/M codes were an attempt to define the intensity of medical service delivered while maintaining some flexibility to accommodate the natural variations found in medical practice.

Although the HCFA saw the 1995 system as an improvement over the prior rules, HCFA thought the E/M definitions were still too vague to allow Medicare auditors to pinpoint the correct level of service to be assigned to the documentation. The 1995 guidelines instructed physicians to conduct a complete single system or a complete multisystem exam, but gave little guidance regarding what constituted a complete exam. When an orthopedist chose to do a comprehensive musculoskeletal examination, for instance, there was no tool to measure when he or she reached the comprehensive level.

With input from HCFA, the CPT committee created the 1997 E/M system, which intended to replace the ambiguity of the 1995 system with a very specific list of bullet items in history, exam and medical decision-making that must be performed and documented to justify a specific level of service.

The new system requires the physician to document everything and tries to make the examination criteria for one discipline comparable to other disciplines to set more universal criteria. This makes it easier for auditors to assess the level of work that was done.

Thomas Kent, CMM, principal of Kent Medical Management, a practice management and consulting business based in Dunkirk, Md., says that HCFA thought the 1997 guidelines were an improvement over 1995s. The 1997 system made it very difficult for physicians to reach the level five service (99205 or 99215, office or other outpatient visit for the evaluation and management of a new (99205)/established (99215) patient), says Kent, and made auditing more precise. But physicians using the 1995 system hated the 1997 system and considered it too complex to utilize on a daily basis, and too inflexible. Both systems are in use today. Kent explains that if audited, HCFA will use the system that is to the advantage of the physician.

Multispecialty vs. Specialty System

According to Lynda Munsey, CPC, coding analyst for the University of Florida at Jacksonville/Physicians Inc., resistance to the 1997 guidelines is based on the notion that from a coding perspective, they require more work for what is essentially a lower yield. The 1997 guidelines, says Munsey, employ a general multisystem exam vs. the specialty system exam of the 1995s. A lot of physicians have the idea that you cannot obtain a comprehensive exam with the multisystem because it is too general. But in reality, a lot of the work that they were doing with the 1995 guidelines was not recorded, because the guidelines were specific to one system. Munsey believes better credit can be given for the work done through the general multisystem exam.

Cheryl A. Scott, CPC, CPC-H, reimbursement manager of orthopaedic surgery at the University of Texas Southwestern Medical Center in Dallas, says that her department employs the 1997 guidelines, but the new version has its drawbacks. Theres a lot more documentation required to reach a comprehensive exam with the new guidelines, says Scott, so it is more work for the physician to reach the correct reimbursement level for the service he provides. Scott explains that the 1995 guidelines make it easier for physicians to document a detailed and comprehensive exam. For example, she says, with the 1995s, the physician can document reflexes in four extremities, any one constitutional measurement, strength in any one muscle (musculoskeletal), sensation in any one location (neurological), orientation (psychological) and has a detailed exam. To obtain the same with the 1997 guidelines, he would need to document 12 bulleted items in his exam. Scott cites another example of a physician who documents everything for a comprehensive exam, except he lists only two vital signs when three are required. In this case, the exam would be reduced to a detailed level due to that one oversight, and that could result in the billing of a lower level of service.

Munsey agrees that the 1997 guidelines can take some getting used to, but feels it is more a problem of physician education. If the doctors arent document-oriented, she says, it is harder to code for a level five visit. But this is a question of educating physicians on how to use the guidelines.

Scott says that for documenting the highest legitimate code for an E/M visit, she pays special attention to medical decision-making. You can do a comprehensive work up and exam on a stubbed toe, says Scott, but youll never get the medical decision-making up to meet the requirements for a level five service. It is not uncommon when doing chart auditing to see the medical decision-making is higher than the level of service that is selected, and it is usually due to the documentation of the exam. Rescoring the same chart with the 1995 exam guidelines often results in a higher level of service. Of course, some of this is that physicians need to understand how the 1997 guidelines work, but it would also be a simpler task with the 1995 guidelines.

Higher-level Codes for Ortho Are Limited

As Scott illustrates with her stubbed toe, for orthopedic coding, there are relatively few opportunities to achieve a level four visit, and even fewer for a level five visit or others that require a comprehensive examination. The problem is not just the daunting number of bullet items that have to be included in an exam (17 for the musculoskeletal system alone, plus 10 in other areas). Even if those criteria are met, the risk of complications and/or morbidity or mortality comes into play as part of the complexity of medical decision-making. Simply put, there just arent that many orthopedic scenarios that require the high complexity medical decision-making required of the higher level codes.

For example, an orthopedist sees a patient with multiple trauma and complex pelvic fractures for evaluation and to formulate a plan of management. This visit would be coded 99244 or 99245 (office consultation for a new or established patient), depending on the level of decision-making required and the amount of time spent face-to-face with the patient.

Another example of a higher level service is when an orthopedic surgeon has an initial hospital consultation for a patient with painless swelling of proximal humerus with lytic lesion by x-ray. This would be coded with 99254 or 99255 (initial inpatient consultation for a new or established patient), depending on the level of decision-making required and the amount of time spent at the bedside or on the patients hospital floor or unit.

1997s Bullets Appear to Be the New Standard

With CPT planning to release new E/M guidelines in the near future, the bullet system of 1997 seems to be here to stay. Munsey, who reviews and assigns codes at a teaching hospital, points out that when considering using the 1995 vs. the 1997 standards, one must take into consideration the current wave of teaching. The physicians, residents and medical students being trained in her program are all being taught to use the 1997 guidelines. In her opinion, If the doctors are giving you the information per the 1997 guidelines, why convert this to the 1995 system? The new guidelines will be bullet-driven, Munsey says, and anyone who can document by the 1997 guidelines will be a superstar when new guidelines are released.

Scott concurs. Everyone, she says, including instructors at two seminars that I attended recently, is recommending staying with the 1997 guidelines. The rationale is that physicians may as well get used to using the bullet method because it will more closely mirror the new guidelines when they come out.