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.

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.

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 mention of complication) and recommends antibiotic ointment and a dressing.

This is an example of straightforward MDM because this is a minor problem that is stable, no diagnostic tests are performed, and a superficial dressing is recommended.

Low complexity (99203, 99213, 99221, 99231, 99234, 99243, 99253, 99261, 99273, 99282): An established patient with a known trigger thumb (727.03, Trigger finger) presents with complaints of increasing pain and clicking. The orthopedist injects the patient's thumb with Celestone and lidocaine. Follow-up care will occur as needed. This is an example of low-complexity MDM because this is an established problem that is worsening, no data were reviewed, and minor surgery with no identified risk factors was performed.

Moderate complexity (99204, 99214, 99222, 99232, 99235, 99244, 99254, 99262, 99274): A new, otherwise healthy patient presents after injuring his left knee while skiing. He presents with an MRI ordered by his primary care physician, which reveals a torn anterior cruciate ligament (ACL). The orthopedist evaluates the patient, reviews the MRI, and discusses surgical and nonsurgical treatment options. This is a new problem with no additional workup planned, and the physician reviewed the MRI and discussed an arthroscopic ACL reconstruction with the patient. This leads to a moderate level of decision-making.

High complexity (99205, 99215, 99223, 99233, 99236, 99245, 99255, 99263, 99275, 99285): An insulin-dependent diabetic (250.8x, Diabetes mellitus) presents with multiple ulcers of the foot. The orthopedist takes an x-ray and determines that the patient also has osteomyelitis of the foot (731.8). The physician arranges to admit the patient to the hospital for emergency surgery and also contacts the patient's endocrinologist to manage the diabetes. The patient has both an established problem (diabetes) that is worsening and a new problem (osteomyelitis) with additional workup planned. The physician has ordered and reviewed x-rays and will perform emergency major surgery on the patient. This scenario would easily qualify as a high level of medical decision-making.

When you are determining and justifying an E/M code, the MDM's complexity for management options and the number of diagnoses are where documentation usually falls short, especially in moderate- to high-risk cases. "The physician should be certain to document the severity of the presenting problem, any underlying diseases that are a factor, all diagnostic tests that have been ordered and/or reviewed, and the various management options that are being contemplated," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J. "Appropriately documenting how the orthopedist arrived at the medical decision is critical when reporting the higher level E/M codes."

To ensure your practice codes appropriately and also gets the proper reimbursement, physicians should write everything down, not just the determined diagnosis, but what was ruled out. "In our office," Ivy says, "if we don't meet all of the required elements for the level of service indicated by the physician, the visit is coded to the level at which all of the required elements are met." This often results in lowering the physician charge but can also raise physician awareness of the need to document thoroughly.