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10 WAYS TO IMPROVE an ASCs ORTHO & SPINE CODING Orthopedic, Spine & PM ASC Conference asc Communications/the ASC Assoc. Conference
Speaker: Stephanie Ellis, R.N., CPC Ellis Medical Consulting, Inc.
(615) 371-1506
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The 10 Ways to Improve Coding
Understanding the coding & billing issues
that can get you into trouble
Learn core basics for assuring the coding
& billing performed at your facility are
correct
Be sure your facility is billing for
incidentals that cost you money – like
Implants
The 10 Ways to Improve Coding
Diagnosis coding is key to being paid
correctly for these procedure – be sure
your understand the basics for correct
diagnosis coding of Ortho/Spine/PM
procedures
Revenue Code and Modifier issues that
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The 10 Ways to Improve Coding
Documentation “Do’s & Don’ts” to keep
you out of trouble
Tips on Common Ortho. procedures that
are frequently miscoded
Understand when Injections for Post-Op
Pain Control are billable – and when they
aren’t
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The 10 Ways to Improve Coding
Putting your best foot forward to code foot
procedures more accurately
Tips to code Spine/Pain Management
procedures correctly
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Coding & Billing Issues
Billing non-covered services as covered services
Billing new procedures (No CPT Code)
Billing Medicare for Cataracts when ASC does NOT purchase the IOL for the case
Upcoding
Unbundling
Failure to Refund Credit Balances timely
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Coding & Billing Issues
Anesthesia Services Scope of Practice violations
Billing improperly for cancelled cases
Transforaminal Injection Med. Necessity issues
Place of Service issues
Inappropriately billing Medicare patients
Changing DOS to correspond with coverage dates
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General Billing Basics/Tips
Read the ENTIRE OP Report before coding
Avoid “Canned” OP reports
Check for proper documentation for Service billed
Review EOBs/RAs for denial reasons
Check CCI Unbundling Material for multiple procedures
Correctly Sequence CPT codes on claim forms
OP Report must identify ASC facility as Place of Service
Read Medicare Bulletins monthly
Be Aware of Medicare LCDs
Use Post-Operative Diagnosis for coding
Are Implants billable to payor?
Are X-rays and Fluoroscopic guidance billable to payor?
Implants
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Implants
Common Implant Codes:
C1713 – Anchor/Screw
L8630 – Metacarpophalangeal Joint Implant
L8631 – Metacarpophalangeal Joint
Replacement Implant
L8641 – Metatarsal Joint Implant
L8642 – Hallux Implant
L8699 or 99070 – Misc. Implants
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Implants
Common Implant Codes (Cont.):
C2614 – Probe for Percutaneous Lumbar Discectomy
C2622 - Prosthesis, Penile, noninflatable
C1778 – Neurostimulator Lead
C1767 – Neurostimulator Generator (nonrechargeable)
C1820 – Neurostimulator Generator (rechargeable)
L8680 – L8688 Misc. Implantable Neurostimulator Components
Q4107 – Graft Jacket
C9361 – Synthetic Conduit for Nerve Repair
* In Most Cases, Do Not Use C-Codes on Medicare Claims.
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Diagnosis Coding – Ortho.
Diagnosis codes provide payors with the “what”
and “why” the service(s) was necessary.
Diagnosis codes provide the tools to report the
Medical Necessity of the service(s) provided.
Over 85% of Medical Necessity claim denials are related to Diagnosis coding!
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Diagnosis Coding – Ortho.
Avoid Upcoding of Injury Diagnoses Removal of Hardware
Arthropathies
Arthropathy Associated with Infections
Traumatic Arthropathy
Internal Derangement of the Knee
Chondromalacia
Degenerative Spine Disorders
Pathological Fractures
Malunion/Nonunion
Valgus vs. Varus
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Diagnosis Coding – Ortho.
Muscle Tears Rotator Cuff Injuries
Impingement Syndrome
Tear/Rupture
Tendinitis and Shoulder Bursitis
Adhesive Capsulitis
Little League Shoulder
SLAP Lesions
Dislocations of Shoulder Joints
Open Injury
Closed Injury
Diagnosis Coding – Ortho.
Tennis Elbow
Other Orthopedic Diagnoses
de Quervain’s Syndrome
Trigger finger
Dupuytren’s contracture
Synovitis
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Diagnosis Coding – Ortho.
Bunions
Bursitis
Ganglions
Paget’s Disease
Osteochondropathies
Flat Foot
17Diagnosis Coding – Ortho.
Other Foot Diagnoses
Hallux Valgus
Hallux Varus
Hallux Rigidus
Hallux Malleus
Hammertoes
Claw Toe
18Diagnosis Coding – Spine/Pain Mgmt.
Spinal Stenosis
Radiculitis
Spondylosis
Enthesopathies
Postlaminectomy Syndrome
Herniated Discs
DDD
Sacral Disorders
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Tips for Appropriate Diagnosis Code
Assignment:
List Diagnosis Chiefly responsible for surgery
first
Avoid Unspecified codes
Do not code from the Alphabetic Index
Acute and Chronic conditions
Link the “what” and “why”
Keep library of Coding books up-to-date
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Tips for Appropriate Diagnosis Code
Assignment: V-Codes
V-Codes: Use for encounters for reason other than
injury or illness
ICD-9-CM definition: Personal History codes
used for a patient with disease in the past but
condition no longer exists (not active) and
patient is not receiving any treatment, however,
the disease has the potential for recurrence and
may require continued monitoring.
V-Codes
Use V-codes for:
Patient history
Family history
Diagnostic tests
Attention to devices
Some symptoms
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E-Codes
E-Codes:
Commonly used on Worker’s
Comp. Claims
Used for how an accident happened
Do not use for Medicare claims
Classify external causes
Not for primary diagnosis
Identify trauma or condition
Late effects of accidental injury
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Revenue Codes
Code 250 for Pharmacy Services
Code 270 for Medical/Surgical Supplies
Code 271 for Non-sterile Supplies
Code 272 for Sterile Supplies
Code 274 for Prosthetic/Orthotic Devices
Code 276 for IOL Implants (Cataracts)
Code 279 for Supplies
Code 278 for Other Implants
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Revenue Codes
Code 320 for X-rays (Fluoroscopy)
Code 360 for Surgical Procedures performed in a Surgical Hospital
Code 370 for General Anesthesia
Code 379 for Other Anesthesia
Code 490 ASC Surgical Procedure CPT codes
Code 710 for Recovery Room Services (PACU)
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Using Modifiers on CPT codes
correctly to help avoid billing
problems and to not leave
money on the table
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Bilateral Procedure Modifiers
Using the correct Modifiers to bill payors for Bilateral Procedures according topayor requirements is very important. The five usual methods for the billing of Bilateral procedures include:
o Bill the same code as two line items, using the –RT Modifier on one code and the –LT Modifier on the other (same) code. (***Medicare)
o Bill the bilateral procedures as two line items with no Modifier on the 1st code and a –50 Modifier on the 2nd line item (same code).
o Bill the procedure as a single line item on the claim form with a –50 Modifier on the procedure code. Be sure if you use this method to double the facility fee.
o Bill the same code as two line items with no Modifiers. (***Medicare) o Bill the procedure as a single line item on the claim form with no Modifier on
the procedure code and put a “2” in the Units column on the claim. Be sure if you use this method to double the facility fee. (***Medicare)
*** Do NOT use the -50 Modifier on Medicare claims.
Modifier Issues
Do NOT use the -51 Multiple Procedure
Modifier on ASC claims, unless the payor
specifically requires its use – it is for use
on physician claims only.
Add-on Codes
Don’t list alone
List code for the Primary procedure before
add-on code
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Correct use of the -59 Modifier on CPT Codes
which are Unbundled or designated as
“Separate Procedures” in the CPT book may
be billable with the use of the –59 modifier, to
indicate that the procedure is not considered a
component of another procedure, but a
distinct, independent procedure, such as a:
o Different site or organ system;
o Separate incision/excision;
o Separate compartment;
o Separate lesion.
o In many cases for Medicare patients, if the code is Unbundled, it is not separately billable.
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Medical Record Documentation
Issues
The medical record must support the Medical Necessity of the CPT and Diagnosis codes billed.
• All entries in the medical record must be dated with a full date (Month/Day/Year) and should be signed by all physicians and nurses recording in the record.
• Patient’s name and/or Medical Record Number should be on every
page in the medical record.
• The medical record should be complete and legible with entries made in black ink.
• Notify the surgeon if a scheduled procedure is not on the Medicare’s list of covered procedures for Medicare patients, and try to divert the case to another setting.
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Medical Record Documentation
Issues
Incomplete OP Reports and Op Report Addendums
o Read the entire OP Report.
o Code only from the OP Report – Never code from the schedule or superbill/chargeticket documents without an OP Report in hand. o Code in a compliant manner – Medicare directs that only those procedures
documented in the body of the OP Report can be billed.
o OP Report Addendums – Addendums should be dated with the date the Addendum is done.
oState it is an “Addendum”.
oAddendums can be done on the original OP Report or on a separate piece of paper.
oIf done on a separate piece of paper, document the date of the original procedure and the procedure performed.
oDo not re-type OP Reports as a new original document. oAddendums can be handwritten by the surgeon or typed. oAddendums must be signed by the surgeon.
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Medical Record Documentation
Issues
“Canned” OP Reports
Issues with “Canned” OP Reports:
“Canned” OP Reports may not contain all of the information necessary for proper documentation of the procedure performed.
Reports may have no Pre- or Post-operative diagnosis tailored to the patient.
The report may contain no language tailored to the patient’s surgery. Report may not list the procedure performed and/or indicate upon which
side (Left or Right) the procedure was performed.
Medicare frowns on the use of “Canned” OP Reports (“Cloned Records”).
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Medical Record Documentation
Issues
OP Report Requirements:
OP Reports must be tailored enough to each individual
surgery and circumstances for use, and not appear to
be “canned”.
Any deviations from normal during surgery, (complication, or a change in something for just that patient’s procedure, etc.) must appear and be correct in the OP report.
Medical Record Documentation
Issues
OP Report Requirements (cont.):
If the report is not accurate, detailed and individualized, it can be a compliance issue.
Consequences:
Can cause the ASC to have to refund money. Can cause an issue with the facility’s state survey.
Can be a potential malpractice issue for both the surgeon and the facility.
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Medical Record Documentation
Issues
Radiology Documentation
When x-rays are taken or fluoroscopy is used in procedures, the physician’s report/interpretation of the findings must be documented. The interpretation can be documented in the OP Report itself or on a separate piece of paper. If no report of the x-ray is documented, do not bill the service.
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Medical Record Documentation Issues
Place of Service Issues with OP Reports
• It can cause problems when Physicians dictate OP Reports off-site from the ASC facility.
• Off-site reports can make it appear that the procedure was performed at the hospital or at the physician’s office, with the ASC not listed as the “place of service” anywhere on the report.
• It is insufficient for the ASC facility to only be listed as “cc:XYZ Surgery Center” at the bottom of the OP Report.
• The ASC could be charged with filing a false and Fraudulent claim, due to it not being clear the procedure was performed at the ASC facility. • It MUST be very clear on the OP Report that the procedure was performed
at your surgery center.
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Medical Record Documentation Issues
Doctor’s Codes on OP Reports
If physicians list diagnosis and/or CPT codes on OP Reports, it does not relieve the ASC’s coder from the obligation of checking through the entire OP Report to be sure the codes given are correct.
Use of Signature Stamps
Medicare and other payors say physicians are not to use signature stamps to sign their OP Reports, H&Ps, etc. If you have physicians using signature stamps, it is wise to discontinue this practice at your ASC.
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Correct Coding of Cases
If you are doing ALL or Most of the coding
for the ASC using superbill documents
where the physicians code, if no one at
your facility is checking the OP Report with
the surgeon’s coding, you are probably
leaving money on the table.
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Hardware Removals
Code 20680 – Deep Implant Removals only code once per fracture site Code 20670 – Superficial Pin Removals
Tendon Grafts with Scope ACL Repairs
Not billable unless harvested from either ankle or opposite knee (code 20924)
Orthopedic Procedures Frequently Miscoded
Lipoma Removals
Use codes from 10000-section (Skin
codes) if removed from just under the
surface of the skin based on size
Deeper lipoma removal procedures should
be coded from the 20000-section with
Excision of Tumor codes based on size
and depth of procedure performed
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Ortho. Procedures Frequently Miscoded
Knee Chondroplasty procedures oChondroplasty = Debridement
oFor Arthroscopic Debridement of ACL, use code 29999 – not 29877 code
oUse Chondroplasty code only once per Knee
oCCI edits for code 29877 mean per Compartment– not that it is not billable
oUse code G0289-GY for Medicare cases with Chondroplasty in separate compartment – not covered for ASC oUse code 29877-59 for other payors for Chondroplasty in
separate compartment
oBill Medicare 29877 when the only procedure performed on knee
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Ortho. Procedures Frequently Miscoded
Synovectomy vs. Debridement Procedures Debridement codes used when articular cartilage is
debrided and Chondroplasty procedures are performed
Synovectomy codes used when only soft tissue is removed, synovium is excised, or plica is excised
Joint Manipulations - perform as an Add-on Procedure only
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Ortho. Procedures Frequently Miscoded
Subacromial Decompressions
– separately
billable with Rotator Cuff Repairs with -59
Modifier if Unbundled
Treatment of SLAP Tears – Scope and Open
codes
Clavicle Procedures – Scope and Open codes
Surgeon should document removed 1 cm. of
bone
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Injections for Post-Op Pain
DON’T bill to Medicare
Must be performed by a different doc
Must have an OP Report separate from
Anesthesia Record and surgery OP Report
Not all payors will reimburse for them
Use codes 64415 or 64416 for Shoulders
Use codes 64447 or 64448 for Knees
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Ortho. Procedures Frequently Miscoded
Abrasion Arthroplasty procedures
Code 29879
Also called Pick Arthroplasties
Surgeon should document procedure was
performed “down to bleeding bone”
Don’t code Chrondroplasty separately with
these procedures
Can code more than once per knee if performed
in a separate compartment
Ortho. Procedures Frequently Miscoded
ACL Procedures
Arthroscopic ACL Reconstruction – code
29888
There is no code for an ACL Debridement
– use Unlisted code 29999
Use code 29888 for an ACL Re-do
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Ortho. Procedures Frequently Miscoded
Epicondylitis procedures
24357 – Percutaneous procedure
24358 – standard Epicondylectomy
24359 – Epicondylectomy with Tendon
work
Manipulation of Elbow - 24300
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Ortho. Procedures Frequently Miscoded
CMC Joint Arthroplasty (Thumb Arthritis)
procedure codes 25447 and 25310 for
tendon transplant in wrist or 26480 for
tendon transplant in CMC area
Dupuytren’s Contractures – percutaneous
vs. more extensive open procedures
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Ortho. Procedures Frequently Miscoded
Foot Procedures
Bunionectomy procedures
Hammertoe Corrections
Code 28285 – Unbundled from Bunion
procedure but separately billable with Toe
Modifiers when performed on a different toe
Use code 28270-59 if MTP Joint Capsulotomy
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Spine/PM Procedures Frequently Miscoded
ESI procedures
Transforaminal ESI procedures
Bundling issues with ESIs
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Spine/PM Procedures Frequently Miscoded
Facet Joint Injections
CPT Code 64490 – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; single level – reimburses $288.44 by Medicare.
CPT Code 64491 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) – reimburses $102.38 by Medicare.
Spine/PM Procedures Frequently Miscoded
Facet Injections, cont.
CPT Code 64492 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) – reimburses $102.38 by Medicare.
CPT Code 64493 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; single level – reimburses $288.44 by Medicare.
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Spine/PM Procedures Frequently Miscoded
Facet Injections, cont.
CPT Code 64494 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) – reimburses $102.38 by Medicare. 95. CPT Code 64495 - Injection(s), diagnostic or
therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) – reimburses $102.38 by Medicare.
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Spine/PM Procedures Frequently Miscoded
SI Joint Injections
o3 Codes – Use depends on circumstances
27096 G0260 20610
Imaging used in procedure
Surgeon and ASC facility’s codes will NOT
match
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Spine/PM Procedures Frequently Miscoded
Discogram Procedures
Bill 64490/64491 codes once per level
Bill 72285-TC or 72295-TC Imaging codes
once per level
Cages used in spine fusion procedures –
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