This document provides information about coding tips for orthopaedic offices. It discusses reimbursement statistics for different orthopaedic procedures, insurance issues to consider, guidelines for evaluation and management visits and other orthopaedic procedures. It also reviews modifiers like 24, 25, and 57 which are important for orthopaedic coding. The presenter has many years of experience in orthopaedic coding and compliance.

1. Coding Tips for the
Orthopaedic Office
Lynn M. Anderanin, CPC,CPC-I, COSC
AHIMA ICD-10-CM Certified Trainer

2. Healthcare Information Services
(HIS)
 HIS is a physician management company based in Chicago,
IL specializing in Revenue Cycle Management and Information
Technology.
 HIS provides services for over 450 providers and has a
dedicated Orthopaedic Division.
 HIS is dedicated to helping physicians maximize their
reimbursement revenue, lower overhead and enhance your
bottom line. HIS is an expert partner for increased
profitability for your Orthopaedic practice.
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3. Presenter - Lynn Anderanin
 Lynn Anderanin, CPC,CPC-I,COSC is the Sr. Director Coding
Compliance and Education for Healthcare Information
Services (HIS). She has over 28 years experience in all areas
of the physician practice including Practice Administrator,
Billing Manager, and Director of Operations. Lynn’s
experience is primarily in the specialties of Orthopedics,
Rheumatology, and Hematology/Oncology.
 She has been a speaker for many conferences, including the
AAPC National Conferences and Workshops, Community
Colleges, audio conferences, and Local Chapters.
 Lynn became a CPC in 1993, and a Certified Instructor in
2002, and a Certified Orthopedic Surgery Coder in 2009.
Lynn is the founder of the first local Chapter of the AAPC in
Chicago, which is now 15 years old, and a former member of
the AAPC National Advisory Board as well as other Boards for
the AAPC.
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4. We will cover ………….
 Reimbursement statistics
 Insurance Issues
 E/M visits
 Visits and procedures
 Injections
 Global surgery period
 Fracture treatment
 Casting and supplies
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5. Reimbursement Statistics
Spine
Office
64% 36%
Outpatient
/Hospital
5

6. Reimbursement Statistics
Total Joints
39% Office
Outpatient
61% /Hospital
6

7. Reimbursement Statistics
Hand
Office
32%
68% Outpatient
/Hospital
7

8. Reimbursement Statistics
General/Sports
Office
46%
54% Outpatient/
Hospital
8

9. Reimbursement Statistics
Pediatrics
28% Office
72% Outpatient
/Hospital
9

10. Insurance Issues
 Insurance eligibility and verification of
benefits
 Patients with deductibles/health savings
accounts
 Workers compensation and liability claims
 Accident Date Information
10

11. Insurance Eligibility and
Verification of Benefits
 Is the patient eligible on the date of service?
 Does the patient have office benefit
coverage?
 Are braces and supplies covered under the
patients plan?
 Does the patient have a Medicare PPO?
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12. Workers Compensation and
Liability Claims
 Is there authorization from the insurance to
see the patient?
 What services are authorized?
 Does the patient have a cap on coverage?
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13. Accident Date Information
Diagnosis Categories that are related
to accidents:
800-897
900-939
950-959
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14. Accident Date Information
 Does the patient information form ask for
accident date information?
 Is the accident date information entered to
show on the claim form?
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15. Part B National Summary
Data File
 https://www.cms.gov/Research-Statistics-Data-and-
Systems/Files-for-Order/NonIdentifiableDataFiles/
PartBNationalSummaryDataFile.html
 Ortho 20
 Hand 40
 http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/downloads/clm104c26.pdf
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16. Comparative Billing Report
 Safeguard Services contracted in 2010
 http://www.safeguard-servicesllc.com/cbr/
default.asp
 E/M reports sent to providers June 4, 2012
 Compares providers to their peers
 CBR and other Data analysis support and
tracking by CMS
http://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Data-analysis/
index.html?redirect=/Data-analysis/
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17. CMS 2009 New Patient Visits
900,000
800,000
700,000
600,000
500,000
400,000 Allowed Services
300,000
200,000
100,000
0
1 2 3 4 5
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18. CMS 2009 Established Patient Visits
5000000
4500000
4000000
3500000
3000000
2500000
Allowed Services
2000000
1500000
1000000
500000
0
1 2 3 4 5
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19. What Level is it?
 Always choose lowest
History Examination MDM common denominator
 New patient- must use all 3
Problem Problem
Straightforward
criteria
Focused Focused
 Established patient- need
Expanded Expanded only 2 of 3 criteria
Problem Problem Low
Focused Focused Answer:
New pt. – Level 2
Detailed Detailed Moderate
Established pt.-Level 4
Comprehensive Comprehensive High
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20. Average Established
Patient Levels
 Level 4- Established patient with a new problem
 Level 3- Current problem still being treated
 Level 2- Problem resolved/stable and/or patient
discharged
20

21. Coding By Time
Documentation Necessary
 Record of total time of the visit as well as the time
spent in the specific counseling or coordination of
care activities.
 The note must include a summary of the content of
the counseling that occurred.
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22. Content of Counseling Summary
 Diagnostic results, impressions, and/or recommended
diagnostic studies
 Prognosis
 Risks and benefits of management (treatment) options
 Instructions for management (treatment) and/or follow-
up
 Importance of compliance with chosen management
(treatment) options
 Risk factor reduction
 Patient and family education
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23. Office/Outpatient Visits
New Patient Visits Established Patient Visits
99201 10 minutes 99211 5 minutes
99202 20 minutes 99212 10 minutes
99203 30 minutes 99213 15 minutes
99204 45 minutes 99214 25 minutes
99205 60 minutes 99215 40 minutes
Office Consultations
99241 15 minutes
99242 30 minutes
99243 40 minutes
99244 60 minutes
99245 80 minutes
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24. Modifier 24
 Modifier 24 indicates the physician
performed an unrelated E/M service during
the post-operative period
 ICD-9-CM codes that clearly indicate the
reason for the encounter was unrelated to
surgical postoperative care may provide
sufficient documentation.
24

25. Modifier 25
 The Centers for Medicare & Medicaid Services
(CMS) has clarified the documentation
requirements and policy requirements for the use
of CPT modifier -25 used with E/M services.
 Please refer to the Medicare Claims Processing
Manual, Publication 100-04,Chapter 12, Section
30.6.6, for revisions regarding the use of CPT
modifier -25.
25

26. Modifier 25
Common Procedural Terminology (CPT)
modifier -25 identifies a significant,
separately identifiable evaluation and
management (E/M) service.
It should be used when the E/M service is
above and beyond the usual pre- and
postoperative work of a procedure with a
global fee period performed on the same
day as the E/M service.
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27. Modifier 25
 Different diagnoses are not required for
reporting the E/M service on the same date as
the procedure or other service with a global fee
period. Modifier -25 is added to the E/M code
on the claim.
 Both the medically necessary E/M service and
the procedure must be appropriately and
sufficiently documented by the physician or
qualified NPP in the patient’s medical record to
support the need for Modifier -25 on the claim
for these services, even though the
documentation is not required to be submitted
with the claim.
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28. Modifier 57
 Carriers pay for an evaluation and management
service on the day of or on the day before a
procedure with a 90-day global surgical period if
the physician uses CPT modifier “-57” to indicate
that the service resulted in the decision to perform
the procedure. Carriers may not pay for an
evaluation and management service billed with the
CPT modifier “-57” if it was provided on the day of
or the day before a procedure with a 0 or 10-day
global surgical period.
 Medicare Claims Processing Manual, Chapter 12
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29. Postoperative Days
 90 days is 90 days, not 3 months.
 Verify that your carriers are following
Medicare postoperative day assignments
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30. Minor Surgery Example
 To determine the global period for minor
procedures, carriers count the day of surgery and
the appropriate number of days immediately
following the date of surgery.
 EXAMPLE:
 Procedure with 10 follow-up days:
 Date of surgery - January 5
 Last day of postoperative period - January 15
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31. Major Surgery Example
 To determine the global period for major surgeries,
carriers count 1 day immediately before the day of
surgery, the day of surgery, and the 90 days
immediately following the day of surgery.
 EXAMPLE:
 Date of surgery - January 5
 Preoperative period - January 4
 Last day of postoperative period - April 5
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32. Injections
There are many different types of injections
 Joint Injections
 20600- Small Joints
 20605- Medium Joints
 20610- Large joints
 27096- Sacroiliac Joint
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33. More Injections
 Tendon Injections
 20550- Tendon Sheath
 20551- Tendon origin/insertion
 Trigger Point(muscle) Injections
 20552- 1 to 2 muscles
 20553- 3 or more muscles
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34. Miscellaneous Injections
 Carpal Tunnel
 20526
 Xiaflex for Dupuytren’s Contracture
 20527 (26341 for manipulation next day)
 Ganglion cyst(s)
 20612
 Bone Cyst(s)
 20615
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35. Normally Not Billed Separately
 Syringes, needles
 Bandages
 Local Anesthesia(e.g. lidocaine,marcaine)
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36. Closed Treatment vs. Visits
AAOS Now-July 2008-
http://www.aaos.org/news/aaosnow/jul08/
managing2.asp
 Physician has the option global or itemized
 Closed treatment should not be billed by
ED physician
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37. 37

38. Casting
CPT Guidelines State:
The services listed below include the
application and removal of the first
cast or traction device only.
Subsequent replacement of cast and/
or traction device may require an
additional listing.
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39. Casting Tips
 Append modifier 58 to casting within the global
period of a procedure
 If a procedure is performed, the initial cast is
included, however the supplies can be billed using
HCPCS codes A4580-A4590, or Q4001-Q4050.
 MedLearn Matters with current casting
reimbursement for Medicare
 http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads//MM7628.pdf
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40. Other Casting Codes
 29700-29715- removal of casts if applied
by another physician
 29730- windowing of cast
 29740-29750- wedging of casts
40

41. Other Supply Codes
 Q4050- Cast supplies unlisted
(waterproof supplies)
 A4565- Sling
 Q4049- Finger splint, static
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42. Supplies and Braces
 Codes found in HCPCS manual
 Separate provider number for Medicare
 See Part A carrier in your jurisdiction
 Fee schedule lists carrier responsible/fees by states
 http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-
Schedule.html
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43. Special Alert
L3660, L3670, L3675 we deleted 12/31/2010
Then this was rescinded, and these codes are still
valid.
 CMS MLN Matters® MM7300
 http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/
MM7300.pdf
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44. Improve Profitability
with HIS
 HIS is a full service Physician Management organization
offering expert services in Revenue Cycle Management,
EHR, Consulting and IT services.
 Expert Coding consultation, Coding Certification
(including ICD-10), training, audits, assessments, etc.
 HIS typically can increase your reimbursements by
10% or more.
 Call HIS to see how we can improve your reimbursements,
lower overhead and boost overall profitability. 1-855-RING-
HIS
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45. RCM plus EHR
 More Orthopedics are using SRS than any other EHR in
the country!
 Bundled service: SRS-EHR and HIS's Revenue Cycle
Management Services together
 Mitigates the up-front costs associated with the software,
hardware and implementation of an EHR purchase.
 HIS will amortize the hardware and software costs into
HIS’ monthly service fee... allowing you to enjoy the
benefits and costs savings with zero capital out-lay.
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46. Contact HIS
 Andy Salmen
 Business Development
 847-720-7007
 asalmen@healthinfoservice.com
 Lynn Anderanin
 Senior Director of Coding Education and Compliance
 847-720-7090
 LAnderanin@healthinfoservice.com
WWW.HealthInfoService.com
1-855-RING-HIS
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