Orthopedic Coding Alert

Coding E/M visits in the orthopedic setting can be a struggle for even the most savvy coder. The documentation requirements needed to reach higher visit levels can be daunting, but there are basic coding and documentation strategies that can always be applied to ease the path to a legitimate, higher level of E/M coding.

Obtaining a higher level of E/M service is less of a challenge in the emergency department (ED) or hospital inpatient setting than in the office because orthopedists are more likely to treat serious trauma injuries there. But in the office or outpatient setting, when you are treating new or established patients, meeting the criteria for coding a high-level E/M service is more challenging. E/M Basics The three central components that determine the E/M service level are history taken at the time of visit, the extent of the physical examination, and medical decision-making (MDM). Malea J. Ivy, RHIT, a coder at the Orthopedic and Neurosurgical Center of the Cascades in Bend, Ore., cautions against overcoding. "CPT guidelines state that each of the key components must meet or exceed the required level to assign that code. We're very careful not to bill higher level codes if one of the key components is not met."

MDM is generally the area that causes the most confusion just what are the differences between straightforward, low, moderate and high complexity? According to CPT's E/M Services Guidelines, "medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the:

1. number of possible diagnoses and/or the number of management options that must be considered

2. amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed

3. risk of significant complications, morbidity and/ or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options." The CMS and American Academy of Orthopedic Surgeons' (AAOS) Guide to CPT Coding for Orthopedic Surgery advocate a four-step process, developed by CMS, for determining the MDM level. Essentially, the AAOS/CMS plan starts with the same three elements but adds "Final Result for Complexity" as a different way of arriving at the same conclusion. The Final Result for Complexity essentially adds up the three CPT items to reach a final outcome for MDM. As with CPT, if two of three items reach a certain level of MDM, the overall MDM for the case is recorded at that level. Examples for MDM Levels Straightforward complexity (99201, 99202, 99212, 99221, 99231, 99234, 99241, 99242, 99251, 99252, 99261, 99271, 99272, 99281): The physician treats an uncomplicated laceration of the finger without tendon involvement (883.0, Open wound of finger[s]; without [...]