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Coding Tips for the Orthopaedic Office Lynn 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 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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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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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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Reimbursement Statistics
36% 64%
Spine
Office
Outpatient/Hospital
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Reimbursement Statistics
39%
61%
Total Joints
Office
Outpatient/Hospital
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Reimbursement Statistics
68% 32%
Hand
Office
Outpatient/Hospital
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Reimbursement Statistics
46% 54%
General/Sports
Office
Outpatient/Hospital
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Reimbursement Statistics
72% 28%
Pediatrics
Office
Outpatient/Hospital
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Insurance Issues Insurance eligibility and verification of
benefits
Patients with deductibles/health savings accounts
Workers compensation and liability claims
Accident Date Information
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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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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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Accident Date Information Diagnosis Categories that are related
to accidents:
800-897
900-939
950-959
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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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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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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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CMS 2009 New Patient Visits
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1 2 3 4 5
Allowed Services
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CMS 2009 Established Patient Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
4000000
4500000
5000000
1 2 3 4 5
Allowed Services
What Level is it? History Examination MDM
Problem Focused
Problem Focused
Straightforward
Expanded Problem Focused
Expanded Problem Focused
Low
Detailed Detailed Moderate
Comprehensive Comprehensive High
Always choose lowest common denominator
New patient- must use all 3 criteria
Established patient- need only 2 of 3 criteria
Answer:
New pt. – Level 2
Established pt.-Level 4
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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
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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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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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Office/Outpatient Visits
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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
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.
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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.
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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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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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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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Postoperative Days 90 days is 90 days, not 3 months.
Verify that your carriers are following Medicare postoperative day assignments
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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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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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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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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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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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Normally Not Billed Separately Syringes, needles
Bandages
Local Anesthesia(e.g. lidocaine,marcaine)
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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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Casting CPT Guidelines State:
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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.
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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Other Casting Codes 29700-29715- removal of casts if applied
by another physician
29730- windowing of cast
29740-29750- wedging of casts
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Other Supply Codes Q4050- Cast supplies unlisted
(waterproof supplies)
A4565- Sling
Q4049- Finger splint, static
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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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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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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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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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Contact HIS Andy Salmen
Business Development 847-720-7007 [email protected]
Lynn Anderanin Senior Director of Coding Education and Compliance 847-720-7090 [email protected]
WWW.HealthInfoService.com
1-855-RING-HIS 46
