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Teri A. Gatchel, MBA, CPC, a consultant with KarenZupko & Associates who is an expert in coding for orthopedic surgery practices,dsicusses four coding challenges and how they can be handled.
1. How can I use ICD-9 Codes to support medical necessity?
In an electronically-driven environment, most of your claims are sent to the payor without manual review, meaning that the information on your CMS-1500 claim form is crucial to getting paid.
For example, your operative note might say there was a complete rupture of the rotator cuff and osteoarthrosis of distal clavicle. To help support two separate procedures, use two separate diagnosis codes: 727.61 (complete rupture of rotator cuff), and 715.11 (osteoarthrosis, localized, shoulder).
2. Can I use the same diagnosis code when performing multiple procedures?
It depends on the procedures performed. Let's say the surgeon performed arthroscopic rotator cuff repair (CPT code 29827), arthroscopic resection of the distal clavicle (CPT code 29824) and arthroscopic subacromial decompression (CPT code 29826). If you reported only one diagnosis of 840.4 (rotator cuff, capsule), you will have difficulty getting paid without using additional diagnosis codes, such as 840.0 (acromioclavicular joint/ligament sprain and strain), 727.61 (complete rupture of rotator cuff) and/or 726.0 (adhesive capsulitis of shoulder).
3. What can I send to the payor to support medical necessity when I have two procedures with the same diagnosis?
Suppose two major joint injections were given in the office — one to the right knee, the other to the right hip. The diagnosis is the same for both injections, therefore you must use modifier -59 ("distinct procedural service") on the second injection to support both services.
4. Are secondary diagnosis codes needed when reporting fractures, accidents and complications?
You can streamline the claims process by using specific diagnosis codes associated with late effects, fracture aftercare and accidents, which I'll now explain.
Late effects codes are used for a long-term effect or residual problem occurring after the acute phase of an injury or illness. These codes range from 905 through 909. Report the late effect along with the code that created the late effect. Code the residual problem as the primary diagnosis and the cause as the secondary diagnosis.
For example, the patient presents with arthropathy as a result of an earlier distal radius traumatic fracture. The original diagnosis, 813.15 (fracture of radius and ulna, open, head of radius), is not reported. Instead, report the following diagnosis codes: 716.13 (traumatic arthropathy, forearm) and 905.2 (late effect of fracture of upper extremities).
To report a newly diagnosed pathologic fracture or during active treatment, use diagnosis codes 733.1X.
V codes, ranging from V01 to V82, are used to describe patients who are not currently ill but see the physician for a specific reason. For example, when a patient completes active treatment, report V codes as the primary diagnosis for routine care. Some situations include cast change, removal of external or internal fixation device, medication adjustment and follow-up visits for fracture treatment outside the global period (usually 90 days).
E codes, ranging from E800 to E999.1, describe the supplementary classification of external causes of injury and poisoning. For example, they may be used to report injuries as a result of work-related accident or auto accidents. These codes provide additional information to the payor to assist with claim adjudication. They are meant to be supplementary codes and should never be used as primary diagnosis codes.
Here is an example on the use of E codes: To report multiple traumatic fractures received as a result of an auto accident, place the fracture codes first (800 to 829.1), followed by E811X to describe the injuries resulting from the accident.
Learn more about KarenZupko & Associates at www.karenzupko.com.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.