The Orthopaedic Coding Coach 2005 Archives

Question:

Can a surgeon bill for regional anesthetic, and if yes, is a digital block considered a regional block?

Answer:

Yes, per the AMA CPT rules a surgeon may bill for regional anesthesia if the surgeon administers the anesthesia and there is no anesthesiologist present. Medicare will not reimburse for any type of anesthesia administered by the operating surgeon. A digital block is considered local anesthesia and is bundled into the surgical package per the AMA.

Question:

We have a patient who was originally seen in our office for a fractured patella. The patient then returned for a new problem which the physician evaluated. We billed the insurance company, but instead of using the new diagnosis, we mistakenly linked the diagnosis for the patella fracture to the second visit. The insurance company paid on 2nd visit. In the meantime, we find out the problem was MVA-related. Now the attorney will not pay unless the bills have the diagnosis for the new problem. The new diagnosis is documented in the physician’s note, but my question is, can we go back and include the new diagnosis on future bills?

Answer:

If I understand your question correctly, the patient was seen originally with a fractured patella. Then on a separate visit, the patient was seen for a new problem, but the fractured patella, instead of the new diagnosis, was linked to the visit on the claim form. The patella fx was not the medical reason for the visit. If this is the correct interpretation, and the physician documented the new problem (not patella fracture) in his or her notes, you should file a corrected claim. It will be important to submit to the auto liability policy and not the typical medical care policy. You most likely will need to refund the primary payor and re-submit the corrected claim to the auto liability carrier and attorney.

When reporting services and linking diagnosis codes which substantiate the medical necessity for the service, it is critical that the physician documents the diagnosis for that visit/service. When there are multiple conditions, the physician should indicate which diagnosis is linked to each E&M, procedure or x-ray on the encounter form. This typically eliminates the error you described.

Second, it is critical at the time of appointment scheduling to ascertain if the visit is workers comp related or auto liability related. Specific and different intake processes are required for each circumstance.

Question:

Our surgeons want to increase their fees when reporting services using the co-surgery modifier. Is this appropriate? We participate in a lot of plans and Medicare.

Answer:

A: Well they can do this – but it doesn’t mean extra payment, when Medicare reimburses on co-surgery services, they increase the allowable by 25% and then divide that new allowable in half and reimburse both surgeons 62.5% of the allowable. Since reimbursement is made on the plan allowable, increasing your fee inflates your charges, but does not necessarily increase your reimbursement from the payor.

Question:

One of the physicians in our group saw a patient in the ER on Sunday night. The next day the patient came to the office and was evaluated by another partner. They are both credentialed as the same specialty, so I think this visit is an established patient visit code, but I want to make sure. Is it a new patient visit or established patient visit when the patient is seen on Monday?

Answer:

Great question and great catch! Since the patient was seen in the ER by one partner (same specialty, same group), the visit on Monday is an established patient visit for the second physician (partner).

Question:

One of our physicians saw a hospital patient for a consultation. He did not perform an exam but spent time talking to the patient and wife. The dictation includes a history and discussion but there is no record of an exam. How can I code the inpatient consult without the exam?

Answer:

You mention that the physician spent time talking to the patient and his wife. Did the physician document the total visit time (unit time) and the percent of the time spent on counseling? If yes, you may choose the correct inpatient consultation code (9925x) based on time. Remember, in the inpatient setting, time is total unit time and not just face to face time. However, the physician must have documented the total time and time spent counseling in the documentation you mentioned.

The second option if the time requirement is not met is to report an unlisted E&M code 99499 and send the claim via paper with the note.

Question:

Our physician submitted the following procedures for the anterior and posterior compartments of the elbow. I was under the impression that the concept of coding compartments does not apply in the elbow but the physician is sure they can be reported separately, just like in the knee. Can you help clarify this for us? The procedures he dictated are:

• Arthroscopic extensive debridement, chondroplasty, and partial synovectomy, anterior compartment left elbow...
• Arthroscopic extensive debridement, chondroplasy, and partial synovectomy, posterior compartment left elbow.

Answer:

The physician is correct in that there are anterior and posterior compartment of the elbow, but unlike the shoulder and knee, coding for arthroscopic procedures in the elbow is not recognized. Thus, the codes for arthroscopic elbow procedures 29830-29838 are for the entire elbow and are not compartment specific. If we apply the same concept in the elbow as we do in the shoulder for limited and extensive debridement, a limited debridement would be debridement in either the anterior or posterior compartment, while extensive debridement would be debridement in both the anterior and posterior compartments.

Question:

Assume a patient is admitted to observation on Friday, and continues to be in observation status on Saturday, then is discharged on Sunday. What E&M code is reported for Saturday’s visit? How do I report the discharge on Sunday?

Answer:

There is not an E&M code (eg, follow-up observation status visit) for the service provided on Saturday. The physician would report an unlisted (eg, 99499) code for the follow-up service provided on Saturday.

The discharge on Sunday is reported using CPT code 99217 observation care discharge.

Question:

Total hip replacement dislocates day 81; the surgeon relocates in the operating room. Do I need a modifier to report the hip relocation?

Answer:

Since you are still in the global period for the original procedure you will need to report the relocation with a -78 modifier ( Return to the OR for a related procedure).

Question:

Orthopaedic Surgeon performs a carpal tunnel release on the right hand. Six weeks later surgeon performs carpal tunnel release on the left hand. The carriers are denying the procedure on the left hand. How should I appeal?

Answer:

The problem for the carrier is that you have the same diagnosis for which you are trying to report another procedure within the global period of the right hand. Appeal with your operative report and attach the modifier -79 for “unrelated procedure or service by the same physician within the global period of another procedure.” It would also help to highlight LEFT hand in the documentation.

Question:

When the hand surgeon removes a pin in the office under fluoro. What code should I report for the removal of the pin?

Answer:

Pins removed in the office are not separately reported. Pin removal may only be reported if removed in the OR, supported by medical necessity. The only reportable service in your scenario is an evaluation and management service.

Question:

Our physician was called to the ER at the request of the ER physician to evaluate the patient. Our physician went to the ER and provided the consultation services. At the end of the service, the physician decided to take the patient to surgery and admit the patient post operatively. The physician wants to bill the OP consult, but I think he should bill the inpatient admission? Who is right?

Answer:

You actually have a choice. You may report an OP consult (9924x) or an IP admission (9922x) but not both. According to the AMA, if a physician is called to the ER at the request of the ER physician, the physician may report an outpatient consultation assuming all the requirements of a consultation are met.

Medicare concurs with this advice as per the following excerpt from the Medicare Carrier Manual:

30.6.11 - Emergency Department Visits (Codes 99281- 99288)

F - Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting

If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met. If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.

Based on this, if the criteria for a consultation are met, the physician bills the outpatient consult, 9924X with the ER as the place of service.

If the physician chooses to report an IP admission (9922x) instead of the consult, the physician does not have to re-perform all of the work that was done in the ER. Instead, the physician may combine the work performed during the ER visit with the work performed at the time of admission and report the 9922x series as the service for the day.

Question:

We added a new physician to our practice. Many of his patients from his previous practice have followed him and are now seeing him in our office. We are trying to determine the appropriate E&M for their initial visit to our office. Is it appropriate to bill the initial visit as a new patient?

Answer:

Per CPT rules if the physician has seen the patient within the past 3 years, he should report the services as an established patient. If the 3 years has expired, then the patient again becomes an established patient.

Question:

One of the clinical assistants in our office is a Certified Athletic Trainer (ATC) who recently passed the test to become an Orthopaedic Technologist, Certified (OTC). She was told she could now bill for her work in the same manner we bill for our Physician Assistant (PA) and Nurse Practitioner (NP) – is that true?

Answer:

Bottom line – No.

The first step in answering your question is to ensure that the services your ATC/OTC will perform in the office are within the scope of practice for your state. For example, casting and splinting might be permitted activities, but medical decision making (i.e. E&M visits) will not be. Reimbursement concerns are secondary to the potential liability of someone working outside their scope of practice. Call your state licensing board for further information. It would be highly unusual for your state’s scope of practice for ATC/OTC to be as broad as those for PA/NP.

Assuming the activities s/he will perform are within your state guidelines, then we turn to reimbursement guidelines. The Medicare Carriers Manual states that PAs, NPs and Clinical Nurse Specialists (CNS) have independent billing rights, meaning once they have been credentialed with Medicare they can bill for services they perform with their name and PIN on the claim form. Medicare is clear that independent billing rights are not afforded to other clinical support personnel, such as ATCs, OTCs, Registered Nurses (RN), Licensed Practical Nurses (LPN/LVN), Orthopaedic Physician Assistants (OPA), Certified Surgical Technicians (CST), Medical Assistants (MA), etc.

Medicare does, however, allow clinical support personnel such as those listed above to assist the physician in patient care with services within their scope of practice, and provides an avenue for reimbursement. These services may be billable under what is known as “incident to” guidelines. When billing under incident to guidelines, the physician’s name and PIN are listed on the claim form. As such, the physician whose name appears on the claim form must be present in the office at the time the service is performed.

Commercial plans can and do have their own rules regarding reimbursement for services performed by non-physician providers and you will need to contact them to determine what services, and under what circumstances, your ATC/OTC may be able to bill. Be sure to ask about supervision requirements as well as potential reimbursement.

Question:

If I am fixing a tibial plateau fracture CPT code 27536 and I do consideral back table work to make a structural allograft work in the case, how would I report that?

Answer:

If the work on the structural allograft made the case much more difficult, this case would be coded 27536-22 to indicate that the work was clearly beyond the range of difficulty that is conventionally required for the ORIF. Do not routinely add a -22 modifier to all allograft cases.

Question:

Can the physician charge an allograft with CPT 27536 (orif tibial plateau fx)?

Answer:

No, allografts may not be reported separately in orthopaedic procedures with the exception of spine cases, which have their own codes for allografts in spine surgery.

Question:

Can we charge for photopcopying records for attorneys, disability claims, etc? I heard that some of our state agencies have a monetary limit but what about private payers?

Answer:

Check your state laws on guidelines for medical record photocopying. Your state's medical association should have this easily available to you. Typically the regulations apply to all payers, not necessarily state vs. private payers.

Question:

Can two surgeons of the same specialty be co-surgeons or can physicians only report services as co-surgeons if they are from different specialties?

Answer:

The AMA revised the definition of modifier 62 Two Surgeons in 1999.

PER AMA CPT:

The following definition for modifier -62 Two Surgeons existed in 1998

“Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the “-62” modifier to the procedure for reporting his services.

In 1999, the AMA revised the definition of modifier-62. Note, the descriptor change is found between side-lying triangles, indicating a change in the descriptor of the guidelines.

“When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single definitive procedure code. If the additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may be reported without the modifier ‘-62’ added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier ‘-80’ or modifier ‘-81’ added, as appropriate.

While the new policy does not specifically state you have to be surgeons of different specialties, there are few examples of where this would be the case.