Hello we have a patient which sustained a fracture injury about 2 weeks ago. She begin seeing another Orthopedic Doctor and started her care with this Doctor. She is under fracture care for this and in the global package for her fracture care with the other providers office. However she wants to move her care to our Surgeons office. My question is how and can we do this and still receive payment for the services since she is under a global with the other Orthopedic office? If so how would this be billed out from our office and if there are any special modifiers that we should be using when billing the services for reimbursement? Thanks in advance for any assistance.
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Tag Archives: Orthopedic
76942 for orthopedic
Hello, I have an orthopedic DR who did an US-guided botox injection for piriformis syndrome, bilateral hips. Per the LCD, G57.01 and G57.02 are not covered. Any suggestions on what code I could use?
Thank you 
Homan’s Sign, Orthopedic or Cardiovascular Exam?
Good afternoon Everyone,
I have a quick question, my provider constantly documents either negative or positive Homan’s sign on his patients and he often bills 99203. On every exam he assesses range of motion (musculoskeletal), tenderness (skin), he documents that the patient is neurovascular intact (neuro) and there are vitals (constitutional); that’s 4 elements which corresponds to an Expanded Problem Focused Exam (99202). He also documents Homan’s sign which according to google it detects DVT and leads me to believe that I should be giving credit towards Cardio under the exam, which is what the provider needs to bill 99203 (detailed exam – 5 exam elements).
Can anyone tell me if I can give credit under Cardiovascular for the Homan’s sign?
Thank you.
Coding Quiz Question for Succss in COding for Orthopedic Complications 3/2018
Question # 10 of the coding quiz asks "Which ICD-10 code is reported for the sequela encounter for a 4-part fracture of the surgical neck of the left humerus? Correct answer is D. S42.432S the rationale being the 7th character place holder S is for sequela. The code description from ICD-10 for S42.432S reads "Displaced fracture (avulsion) of lateral epicondyle of left humerus. The code description for S42.242S, which seems to describe the condition exactly reads "4-part fracture of surgical neck of left humerus" was not an option. Can you please explain why?
Orthopedic surgery coding guidelines – complete 2 series surgery codes
Hi everyone,
I am trying to locate a complete surgery training material for Ortho – 2 series codes.
Can anyone guide me in locating the same.
IT will be of great help, if I can be shared with good training reference links
Thanks in advance
Regards,
Asha.V
Orthopedic Medical Transcription Company in the US
Accurate and up-to-date maintenance of orthopedic medical records can be a very time consuming process for medical practitioners. Now HIPAA approved medical transcription companies take care of the transcribing of all medical records and cut down on the workload while preventing the build up of pending documents. A reliable orthopedic medical transcription company in the US efficiently delivers well documented orthopedic records within a very short time.
Superior Quality Transcription
All aspects of orthopedic medical records which include patient histories, referrals, clinic notes, diagnostic reports, x-ray reports, laboratory summaries, physical examination notes, operative reports and others are transcribed using state-of-the-art technology by transcription firms. Both short and long term services are provided by the HIPAA compliant firms that adhere to quality guidelines and turnaround time with great precision. These companies are reliable and reduce the burden of the orthopedic doctors and other related professionals to a great extent while delivering accurate transcripts within a very short period of time.
Error-free Confidential Delivery of Transcribed Documents
The medical transcription companies have a team of experts which include transcriptionists, editors, proofreaders and others who work efficiently to ensure that the documents are accurate. The multi-level checks ensure error-free documents. Moreover, these firms follow FTP or File Transfer Protocol for transfer of transcribed data through encrypted sites. This ensures total privacy and security of the reports that are delivered back in the form of files. These files have easy retrieval system which makes it easy for any authorized person to refer to them anytime. Formatting of the delivered text of the transcribed documents cans also be customized according to client need. The customer support team of these private transcription services is very efficient and is available round the clock.
A reliable orthopedic medical transcription company in the US could make a lot of difference to orthopedic medical professionals and ease their workload, enabling them to save time and effort. Since good quality transcripts are delivered within a very short period of time, this arrangement works out very well for most healthcare units and practitioners.
Medical Transcription Company – MTS Transcription Services (MTS) is a medical transcription service company providing hospitals, outpatient clinics, physicians and health care facilities of all specialties, with quality medical transcription services.
Auditing Orthopedic Exam-
Palmetto GBA has stated " the 1995 detailed exam requires documentation of throw through seven body areas or organ systems with more detail. Detailed exam would consist of at least two finding for at least two body areas or two organ systems."
For example, "Pt A&O with pleasant mood and affect. Examination of Lt Knee shows incisions clean, dry and intact, good capillary refill. Skin is unremarkable. Full ext present, flex to 95. No signs infection or RSD. Neurovascularly intact distally. Good endpoint w/ anterior and posterior drawer. Rt knee normal exam -ROM, STR, capillary refill, stability and sensation all intact.
I score the exam as Expanded (1995: 5 organ systems // 1997:2 ROM, 2 STR, 1 Inspection, 1 Skin, 2 Psych, 1 Neuro, 1 Cardiovascular)
However, with the Palmetto GBA guidance, should the exam be enough for a detailed exam? The other coder in our office thinks I should require at least 4 findings for two body areas, which honestly is what I’ve been doing.
AHA Coding Clinic for ICD-10 covers orthopedic, cardiovascular coding
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
I never thought I’d be so eager to read a release about coding instead of the newest James Patterson novel, but this newsletter highlighted topics such as orthopedic screw removals, revision of total knee replacements, heart failure with pleural effusions, leadless pacemakers, the Glasgow Coma Scale, and decompression of the spinal cord.
Orthopedics
Typically, when we see that a device is loose or breaking, we automatically think "that shouldn’t happen," so we opt to code a complication of the device. Well, when this occurs in an orthopedic screw as an expected outcome (typically when the patient begins bearing weight during the recovery/healing process), it should not be coded as a complication.
The correct diagnosis codes would be assigned for the specified fracture site with a seventh character identifying a subsequent encounter with routine healing, along with the external cause code (if known), also as a subsequent encounter. (Remember that place of occurrence, activity, and status codes should only be used for the initial encounter, per the ICD-10-CM Official Guidelines for Coding and Reporting.)
The ICD-10-PCS root operation would be Removal (third character P) for the removal of the screw from the specified bone.
On the other hand, some orthopedic devices can present real complications necessitating removal and replacement. For example, a patient may be admitted for a painful total knee replacement, initial encounter (T84.84xA). In order to remedy this situation, the previously placed components (tibial and femoral) are removed and replaced with new components. This scenario leads coders to ponder whether this should be considered a Revision or Replacement, or perhaps something else.
ICD-10-PCS defines a Revision as "correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device." In this case, the prosthesis isn’t working exactly the way it should, but the ICD-10-PCS Reference Manual states that "putting in a whole new device or a complete redo is coded to the root operation(s) performed."
Therefore, the correct root operations would be Removal (P) for taking out the old components, then a Replacement (third character R) for putting in/on a synthetic material that takes the place of the body part.
Cardiovascular
I am confident many coders noticed that the codes for heart failure (category I50) are mostly identical to their ICD-9-CM counterparts.
But one thing that probably raised some eyebrows for coders was the Excludes2 note at category J91 (Pleural effusion in conditions classified elsewhere), which seemed to state that a code from category J91 would be assigned as an additional code when seen "in heart failure."
Of course, most coders will recall that in ICD-9-CM we normally could not assign a separate code for this situation, based off information in AHA Coding Clinic for ICD-9-CM, Third Quarter 1991. The new issue provides clarification that the same rules apply in ICD-10-CM for pleural effusions seen in heart failure patients.
The pleural effusions would only be reported separately if therapeutic/diagnostic interventions are required. Pleural effusion is commonly seen with congestive heart failure (CHF) with or without pulmonary edema. Usually, the effusion is minimal and resolves with aggressive treatment of the underlying CHF.
The issue also addresses the correct coding of a newer procedure performed for heart blocks: the insertion of leadless pacemakers. You may have asked, as I did, how in the world does this device work if there are no leads to provide the electrical impulses?
This technology has been explored for many years and is finally here. Current pacemaker devices are susceptible to issues such as lead failure or malpositioning, as well as pulse generator pocket complications, such as scar formation or even just the visible presence of the device. In contrast, these new cylindrical devices fit directly into the right ventricle, accessed via a transcatheter approach and placed into the endocardial tissue of the right ventricular apex to provide pacing capabilities.
For coding purposes, the ICD-10-PCS table 02H (Insertion, heart and/or great vessels) does not provide a specific device option for a leadless pacemaker. The correct device character should be D (intraluminal device). The full ICD-10-PCS code to be assigned is 02HK3DZ (Insertion of intraluminal device into right ventricle, percutaneous) to identify a leadless pacemaker.
Neurology
Revisions in ICD-10-CM allow coders not only to report a coma (R40.20-, unspecified coma) but also to report codes that incorporate a common tool to assess the depth and duration of comas or impaired consciousness, known as the Glasgow Coma Scale.
Per the Centers for Disease Control and Prevention, this scale helps to gauge the impact of a variety of conditions, such as acute brain damage due to traumatic and vascular injuries or infections and metabolic disorders (e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis).
ICD-10-CM contains subcategories to report the three elements that go into calculating the coma scale:
- R40.21-, coma scale, eyes open
- R40.22-, coma scale, best verbal response
- R40.23-, coma scale, best motor response
If coders opt to use this reporting option, three codes must be assigned to identify each of the three elements.
Codes for the individual Glasgow Coma Scale scores from these categories can be assigned if the provider documents the numeric values, as opposed to the physical descriptions associated with those numeric values.
The eye opening response is scored as follows:
- 4, spontaneous eye opening
- 3, eyes open to speech
- 2, eyes open to pain
- 1, no eye opening
The verbal response is divided into five categories:
- 5, alert and oriented
- 4, confused, yet coherent, speech
- 3, inappropriate words and jumbled phrases consisting of words
- 2, incomprehensible sounds
- 1, no sounds
The motor response is divided into six different levels:
- 6, obeys commands fully
- 5, localizes to noxious stimuli
- 4, withdraws from noxious stimuli
- 3, abnormal flexion, i.e., decorticate posturing, an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest
- 2, extensor response, i.e., decerebrate posturing, an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, and head and neck arched backwards
- 1, no response
For example, the documentation states "Glasgow Coma Scale score was obtained upon arrival at the ED; eyes open = 2, best verbal = 3, and best motor = 5." Coders may assign the following:
- R40.2122, coma scale, eyes open, to pain, at arrival to ED
- R40.2232, coma scale, best verbal response, inappropriate words, at arrival to ED
- R40.2352, coma scale, best motor response, localizes pain, at arrival to ED
Per the Official Guidelines, the seventh characters must match for all three codes.
Subcategory R40.24- (Glasgow Coma Scale, total score) is an additional option provided that identifies the overall score as opposed to each of the three individual elements.
Those codes are:
- R40.241, Glasgow Coma Scale score 13-15
- R40.242, Glasgow Coma Scale score 9-12
- R40.243, Glasgow Coma Scale score 3-8
- R40.244, other coma, without documented Glasgow Coma Scale score, or with partial score reported
Codes from R40.24- would not be assigned if the individual scores are documented.
Procedurally, Coding Clinic provided clarification regarding decompressive laminectomies and the assignment of the appropriate body part characters. When assigning an ICD-10-PCS code for a cervical decompressive laminectomy, the body part value states "cervical spinal cord."
The cervical spinal cord is considered a single body part value in ICD-10-PCS and would only be assigned one time regardless of the number of cervical levels decompressed to release the spinal cord.
The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically; therefore, ICD-10-PCS Guideline B3.2 does not apply:
During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body sites that are included in the same body part value.
Another note of caution: The ICD-10-PCS Index entry "Laminectomy" instructs coders to see Excision (B), but the objective of a decompressive laminectomy is to release pressure and free up the spinal nerve root. Therefore, the appropriate root operation is Release (N).
Editor’s note: McCall is the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see www.hcprobootcamps.com.This article was originally published in Briefings on Coding Compliance Strategies.
New Podiatrists in our Orthopedic Office
Two Podiatrists have recently joined our busy Orthopedic practice. They have yet to be credentialed with all payers. Is it appropriate for them to see patient’s under the supervision of our Orthopedics MD’s? ( including billing) We have done this in the past when new Orthopedists have joined. I am unsure if this is acceptable since it is two different specialties. I cannot seem to find any literature on it.
Thanks
Thanks
Orthopedic Coding Rules: Master the ‘Multiple Scope’ Rule
If your orthopedist carries out several procedures during a knee arthroscopy on the same patient on the same day, you will need to understand the multiple-scope rule to determine which procedures you can actually claim and get the payments too.
Vital orthopedic exception: Remember that the multiple-scope rule applies mainly to shoulder and knee procedures in the orthopedic practice; however it also affects those of the elbow, wrist and hip. On the contrary, it doesn’t apply to ankle or metacarpophalangeal (MCP) arthroscopy, and it does not affect arthroscopically aided procedures (29851, 29855-29856, 29888-29889 and 29892).
Follow these expert-approved tips to clinch your coding every time
1. Look to CPT for scope ‘families’
Prior to worrying about how to apply the multiple-endoscopy rule, you should first know why and when it applies.
The multiple-endoscopy rule is Medicare’s method to avoid paying twice (or more) for ‘inclusive’ services by reimbursing only a portion of any scope carried out at the same time as another scope of the same basic type.
2. Always include the ‘base’ procedure
Let us assume that the doctor has carried out a diagnostic shoulder arthroscopy (29805) plus shoulder arthroscopy for repair of SLAP lesion (29807). How does the multiple-scope rule apply?
Remember that family codes always include the work involved in the base code, and a surgical scope always includes the diagnostic scope of the same type. As such, you would report only 29807 in this case.
What about diagnostic shoulder arthroscopy followed by arthroscopic limited debridement? Once more, you should report only the more extensive procedure – in this case, 29822 (Arthroscopy, shoulder, surgical; debridement, limited).
3. Bill both scopes if there’s no base procedure
If the surgeon carries out two scopes in the same family, neither of which is the base procedure, you should go for both codes. As such, if your orthopedist carries out shoulder arthroscopy with foreign-body removal (29819) followed by shoulder arthroscopy for complete synovectomy, you would submit both 29819 and 29821 (… synovectomy, complete).
4. Watch your reimbursement
Under the multiple-scope rule, Medicare will pay the entire fee schedule amount only for the highest-valued scope in a given code family during the same operative session. Medicare carriers will reimburse any additional scopes in the same family by subtracting the value of the base scope in that family and paying the difference.
For more details on this and for other orthopedic coding updates, sign up for an audio conference and stay informed.
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