3 Tips for Coding and Billing Common Orthopedic Procedures:

1) Keep Abreast of Coding Updates

The American Medical Association rolls out a number of changes to its Current Procedural Terminology code set each year.

Changes in 2014, according to Becker’s ASC Review report, included:

Codes related to removal of foreign bodies, prosthesis removal and knee procedures. The new codes include 23333 to 23335, 27415 and 27524. “Code 27415 for open osteochondral allograft, knee, open, is an existing CPT code, which is newly-added to the Medicare ASC list for 2014 with an average Medicare payment of $2,242,” said Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting, in the report. There were also changes made to arthroscopic knee synovectomy codes 29875 and 29876. “Medicare no longer allows either of these codes to be billed when any other arthroscopic procedure is performed on the same knee in the same surgical case, due to strict enforcement of the CCI edits,” said Ms. Ellis. Strict CCI edit enforcement has also extended to include codes involving some arthroscopic shoulder procedures. The AMA is expected to announce the 2015 CPT code change, which will go into effect Jan. 1, 2015.

2) Track and Avoid Common Denials and Reason Codes

Here are the five most common unexpected orthopedics claim denials that occurred from Oct. 19, 2013 to Jan. 16, 2014, according to RemitDATA.

  • CPT code 99213: Outpatient doctor visit, level 3
  • CPT code 20610: Aspiration and/or injections; major joint or bursa
  • CPT code 99203: Outpatient doctor visit, new patient, level 3
  • CPT code 99214: Outpatient doctor visit, level 4
  • CPT code 97110: Therapeutic exercises

The top reason codes for these unexpected denials include:

  • Reason code 45: Charge exceeds fee schedule
  • Reason code 23: Prior payer(s) adjudication affected this payment and/or adjustment
  • Reason code 18: Duplicate claim/service
  • Reason code 59: Processed based on multiple or concurrent procedure rules
  • Reason code 223: Mandated adjustment code when other code not applicable

Track the root causes of common denials and put processes in place to avoid these denials in the future. Three key actions to take to avoid denials, according to a Health Information Services report, include:

  • Diligent insurance verification
  • Accurate patient information collection
  • Selecting an automated billing service

3) Understand ICD-10 Changes

ICD-10 affects every specialty in medicine, including orthopedics. Here are five ICDA-10 changes in orthopedics coding to expect, according to Kareo.

  • Site specificity. Many orthopedics diagnoses will require documentation of specific regions of the body. For example, a diagnosis of spondylosis or spinal stenosis will require physicians to indicate the specific region of the spine.
  • Laterality. ICD-9 codes did not capture laterality, but in the ICD-10 code set physicians must document left, right or bilateral for a number of conditions, such as joint disorders and fractures.
  • Type of encounter. Physicians will need to document with a level of specificity high enough that coders can understand if the encounter was initial, subsequent or sequela.
  • Combination codes. There are not many orthopedic combination codes in ICD-10, but they do exist. For example, M54.4 indicates lumbago with sciatica.
  • Place of occurrence codes. ICD-10’s largest demand is for more specificity. Payers will need to see documentation of where an injury occurred, for example code Y92.250 indicates an injury took place in an art gallery.

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