Coding Tips for theOrthopaedic OfficeLynn M. Anderanin, CPC,CPC-I, COSC AHIMA ICD-10-CM Certified Trainer
Healthcare Information Services             (HIS)  HIS is a physician management company based in Chicago,  IL specializi...
Presenter - Lynn Anderanin  Lynn Anderanin, CPC,CPC-I,COSC is the Sr. Director Coding  Compliance and Education for Healt...
We will cover ………….  Reimbursement statistics  Insurance Issues  E/M visits  Visits and procedures  Injections  Glob...
Reimbursement Statistics         Spine                 Office   64% 36%                 Outpatient                 /Hospit...
Reimbursement Statistics       Total Joints          39%   Office                Outpatient 61%            /Hospital      ...
Reimbursement Statistics          Hand                 Office     32%        68%      Outpatient                 /Hospital...
Reimbursement Statistics       General/Sports                Office       46%     54%        Outpatient/                Ho...
Reimbursement Statistics           Pediatrics     28%          Office       72%        Outpatient                  /Hospit...
Insurance Issues  Insurance eligibility and verification of  benefits  Patients with deductibles/health savings  account...
Insurance Eligibility and      Verification of Benefits  Is the patient eligible on the date of service?  Does the patie...
Workers Compensation and        Liability Claims  Is there authorization from the insurance to  see the patient?  What s...
Accident Date InformationDiagnosis Categories that are relatedto accidents:                800-897                900-939 ...
Accident Date Information  Does the patient information form ask for  accident date information?  Is the accident date i...
Part B National Summary          Data File  https://www.cms.gov/Research-Statistics-Data-and-  Systems/Files-for-Order/No...
Comparative Billing Report  Safeguard Services contracted in 2010    http://www.safeguard-servicesllc.com/cbr/    defaul...
CMS 2009 New Patient Visits900,000800,000700,000600,000500,000400,000                       Allowed Services300,000200,000...
CMS 2009 Established Patient Visits  5000000  4500000  4000000  3500000  3000000  2500000                                A...
What Level is it?                                                  Always choose lowest   History     Examination        ...
Average Established             Patient Levels  Level 4- Established patient with a new problem  Level 3- Current proble...
Coding By Time  Documentation Necessary  Record of total time of the visit as well as the time  spent in the specific cou...
Content of Counseling Summary  Diagnostic results, impressions, and/or recommended  diagnostic studies  Prognosis  Risk...
Office/Outpatient VisitsNew Patient Visits          Established Patient Visits99201 10 minutes             99211 5 minutes...
Modifier 24  Modifier 24 indicates the physician  performed an unrelated E/M service during  the post-operative period  ...
Modifier 25  The Centers for Medicare & Medicaid Services  (CMS) has clarified the documentation  requirements and policy...
Modifier 25Common Procedural Terminology (CPT)modifier -25 identifies a significant,separately identifiable evaluation and...
Modifier 25  Different diagnoses are not required for  reporting the E/M service on the same date as  the procedure or ot...
Modifier 57  Carriers pay for an evaluation and management  service on the day of or on the day before a  procedure with ...
Postoperative Days  90 days is 90 days, not 3 months.  Verify that your carriers are following  Medicare postoperative d...
Minor Surgery Example  To determine the global period for minor  procedures, carriers count the day of surgery and  the a...
Major Surgery Example  To determine the global period for major surgeries,  carriers count 1 day immediately before the d...
InjectionsThere are many different types of injections  Joint Injections      20600- Small Joints      20605- Medium Jo...
More Injections  Tendon Injections    20550- Tendon Sheath    20551- Tendon origin/insertion  Trigger Point(muscle) In...
Miscellaneous Injections  Carpal Tunnel    20526  Xiaflex for Dupuytren’s Contracture    20527 (26341 for manipulation...
Normally Not Billed Separately  Syringes, needles  Bandages  Local Anesthesia(e.g. lidocaine,marcaine)                 ...
Closed Treatment vs. VisitsAAOS Now-July 2008-  http://www.aaos.org/news/aaosnow/jul08/  managing2.asp  Physician has the...
37
CastingCPT Guidelines State:   The services listed below include the   application and removal of the first   cast or trac...
Casting Tips  Append modifier 58 to casting within the global  period of a procedure  If a procedure is performed, the i...
Other Casting Codes  29700-29715- removal of casts if applied  by another physician  29730- windowing of cast  29740-29...
Other Supply Codes  Q4050- Cast supplies unlisted  (waterproof supplies)  A4565- Sling  Q4049- Finger splint, static   ...
Supplies and Braces  Codes found in HCPCS manual  Separate provider number for Medicare  See Part A carrier in your jur...
Special AlertL3660, L3670, L3675 we deleted 12/31/2010  Then this was rescinded, and these codes are still  valid.  CMS M...
Improve Profitability             with HIS  HIS is a full service Physician Management organization  offering expert serv...
RCM plus EHR  More Orthopedics are using SRS than any other EHR in  the country!  Bundled service: SRS-EHR and HISs Reve...
Contact HIS  Andy Salmen    Business Development    847-720-7007    asalmen@healthinfoservice.com  Lynn Anderanin   ...
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Coding tips for busy orthopaedic practices

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Coding tips for busy orthopaedic practices

  1. 1. Coding Tips for theOrthopaedic OfficeLynn M. Anderanin, CPC,CPC-I, COSC AHIMA ICD-10-CM Certified Trainer
  2. 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. 2
  3. 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. 3
  4. 4. We will cover ………….  Reimbursement statistics  Insurance Issues  E/M visits  Visits and procedures  Injections  Global surgery period  Fracture treatment  Casting and supplies 4
  5. 5. Reimbursement Statistics Spine Office 64% 36% Outpatient /Hospital 5
  6. 6. Reimbursement Statistics Total Joints 39% Office Outpatient 61% /Hospital 6
  7. 7. Reimbursement Statistics Hand Office 32% 68% Outpatient /Hospital 7
  8. 8. Reimbursement Statistics General/Sports Office 46% 54% Outpatient/ Hospital 8
  9. 9. Reimbursement Statistics Pediatrics 28% Office 72% Outpatient /Hospital 9
  10. 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. 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? 11
  12. 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? 12
  13. 13. Accident Date InformationDiagnosis Categories that are relatedto accidents: 800-897 900-939 950-959 13
  14. 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? 14
  15. 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 15
  16. 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/ 16
  17. 17. CMS 2009 New Patient Visits900,000800,000700,000600,000500,000400,000 Allowed Services300,000200,000100,000 0 1 2 3 4 5 17
  18. 18. CMS 2009 Established Patient Visits 5000000 4500000 4000000 3500000 3000000 2500000 Allowed Services 2000000 1500000 1000000 500000 0 1 2 3 4 5 18
  19. 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 4Comprehensive Comprehensive High 19
  20. 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. 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. 21
  22. 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 22
  23. 23. Office/Outpatient VisitsNew Patient Visits Established Patient Visits99201 10 minutes 99211 5 minutes99202 20 minutes 99212 10 minutes99203 30 minutes 99213 15 minutes99204 45 minutes 99214 25 minutes99205 60 minutes 99215 40 minutes Office Consultations 99241 15 minutes 99242 30 minutes 99243 40 minutes 99244 60 minutes 99245 80 minutes 23
  24. 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. 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. 26. Modifier 25Common Procedural Terminology (CPT)modifier -25 identifies a significant,separately identifiable evaluation andmanagement (E/M) service.It should be used when the E/M service isabove and beyond the usual pre- andpostoperative work of a procedure with aglobal fee period performed on the sameday as the E/M service. 26
  27. 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. 27
  28. 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 28
  29. 29. Postoperative Days  90 days is 90 days, not 3 months.  Verify that your carriers are following Medicare postoperative day assignments 29
  30. 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 30
  31. 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 31
  32. 32. InjectionsThere are many different types of injections  Joint Injections   20600- Small Joints   20605- Medium Joints   20610- Large joints   27096- Sacroiliac Joint 32
  33. 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 33
  34. 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 34
  35. 35. Normally Not Billed Separately  Syringes, needles  Bandages  Local Anesthesia(e.g. lidocaine,marcaine) 35
  36. 36. Closed Treatment vs. VisitsAAOS 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 36
  37. 37. 37
  38. 38. CastingCPT 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. 38
  39. 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 39
  40. 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. 41. Other Supply Codes  Q4050- Cast supplies unlisted (waterproof supplies)  A4565- Sling  Q4049- Finger splint, static 41
  42. 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 42
  43. 43. Special AlertL3660, 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 43
  44. 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 44
  45. 45. RCM plus EHR  More Orthopedics are using SRS than any other EHR in the country!  Bundled service: SRS-EHR and HISs 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. 45
  46. 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 46

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