 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Global package › Pre-op H&P › Consent › Local anesthesia › Surgery › Simple wound irrigation › Intra-op x-rays › Suture removal › Post-op follow-up (0, 10, 90 days)

 Current Procedural Terminology (CPT) › Code breakdown  10% pre-op assessment  69% surgery  21% post-op follow-up care

 Relative Value Unit (RVU) › Total › Work › Facility vs. non-facility  How they generate a new code How they generate a new code

 Elbow fracture, surgery with ulnar nerve exposure  Codes 1. Elbow ORIF alone 2. Wound irrigation with elbow ORIF 3. Wound irrigation with elbow ORIF and ulnar neuroplasty

 Elbow fracture, surgery with ulnar nerve exposure  Codes 1. Elbow ORIF alone 2. Wound irrigation with elbow ORIF 3. Wound irrigation with elbow ORIF and ulnar neuroplasty

 Open elbow fracture with ring/small finger numbness, surgery with ulnar nerve exposure  Codes 1. Elbow ORIF alone 2. Wound irrigation with elbow ORIF 3. Wound irrigation with elbow ORIF and ulnar neuroplasty

 Open elbow fracture with ring/small finger numbness, surgery with ulnar nerve exposure  Codes 1. Elbow ORIF alone 2. Wound irrigation with elbow ORIF 3. Wound irrigation with elbow ORIF and ulnar neuroplasty

 Correct Coding Initiative (CCI) Edits › Bundled services  Prep and drape  Local anesthesia by surgeon  Surgery (open, closed, percutaneous)  Drains and pumps at same surgical site  Cultures  Access through damaged tissue; repair  Intra-op complications and management

 Modifiers › Procedure altered in circumstance › Procedural definition unchanged › Two-digit attached to CPT code

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Sections › Skin and nails › Orthopaedic › Vascular › Neurosurgery › Medicine (includes wound care)

 Orthopaedic section › Spine › Shoulder › Humerus and Elbow › Forearm and Wrist › Hand and Fingers › Pelvis and Hip › Femur and Knee › Leg and Ankle › Foot and Toes

 Categorical › Incision › Excision › Introduction or Removal › Repair, Revision, Reconstruction › Fracture and Dislocation › Arthrodesis › Amputation › Other

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Symbols Ø Modifier -51 exempt + Add-on code Suture of digital nerve each additional nerve use of operative microscope ▲ Revised code ● New code * Service includes surgical procedure only * Injections; tendon sheath

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Patient had morbid obesity, and femur nailing took twice as long

 Femur IMN -22

 Patient taken to OR for femur IMN, but because BP dropped upon induction, anesthesia canceled the case

 Femur IMN -53

 Open elbow fracture with ulnar nerve injury, undergoing ORIF and I&D

 ORIF  I&D -51  Ulnar neuroplasty

 Day 1 › ORIF of distal radius  Day 14 › Repeat ORIF because of collapse

 Day 1 › ORIF of distal radius  Day 14 › Repeat ORIF because of collapse  Day 1: Radius ORIF  Day 2: Radius ORIF -78

 Day 1 › ORIF of distal metaphyseal radius  Day 14 › Repeat ORIF because poor fixation of unrecognized intra-articular split

 Day 1 › ORIF of distal metaphyseal radius  Day 14 › Repeat ORIF because poor fixation of unrecognized intra-articular split  Day 1: Radius ORIF  Day 2: Radius intra-artic ORIF -58

 Day 1 › I&D of forearm wound, but still needing second debridement  Day 5 › Repeat I&D of forearm wound

 Day 1 › I&D of forearm wound, but still needing second debridement  Day 5 › Repeat I&D of forearm wound  Day 1: I&D, and DICTATE PLAN  Day 2: I&D -58

 -22: Unusual procedural services › Scarring, bleeding, obesity, etc. › 25% fee increase › Must quantify extent of complexity

 -50: Bilateral procedure › Payment is 150% of the single code  -51: Multiple procedures › Payment at 50% ( ) › Doesn’t always apply; some codes are exempt Ø 51 modifier exempt codes + Add-on codes

 -53: Discontinued procedure › Surgery or anesthesia started, but case terminated due to certain circumstances

 -54: Surgical care only › Bills surgical portion of CPT  -55: Postoperative management only › Bills for post-op component of CPT

 -58: Staged procedure › Must meet ONE of the following:  Planned prospectively, or  Second stage more extensive than first, or  Definitive surgery after a diagnostic procedure › This sets the global period clock › Example:  Closed tx of distal radius, then to OR for open treatment

 -59: Distinct procedural service › Used to bypass CCI edits ONLY when appropriate › Situations (same calendar day services)  Separate incision  Separate area  Separate diagnosis  Separate session

 -78: Return to OR during post-op period › For post-op complications (that don’t meet -58 conditions) › Global period does not reset › Payment reduction

 -79: Unrelated procedure during post-op period › Make sure there is a new diagnosis › New global period established › Track both global periods separately

 Finger and toes › FA: Left Thumb › F1: Left Index Finger … › F9: Right Small Finger › TA, T1–T9: Toes

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Principles to remember › Everything you DO has a CPT code  E/M  Casting  Closed reduction  ORIF › Every CPT code must have a valid REASON (ICD-9 code) › Add modifiers when circumstances dictate › AAOS’s Code X 2012 software can help

 Case 1 › 10 y/o patient falls on scooter › Displaced R radius and ulna shaft fxs › Angulated L radius and ulna shaft fxs

 Case 1 › You perform open treatment of the R radius and ulna fxs, and closed manipulation and splinting of the L side.

 Case 1 › Code set / Wrist pain / outpt consult, with decision for surgery / 25574Open tx R radius/ulna shaft fxs / Closed manipulation of L radius/ulna shaft fxs  -51: Multiple procedure  50% discount  59: Distinct procedural service on the same day  Separate site

 Case 2 › 25 y/o patient falls from motorcycle › R open distal radius displaced intra-artic fx › Manipulation performed in ED for preliminary stabilization › Taken to OR that evening  I&D of open fx  ORIF

 Case 2 › Code set / Complex open wound / consult, decision for surgery / 25605Closed tx radius with manip in ED / Open tx radius in OR / I&D of skin to bone assc with open fx  -51: Multiple procedure  50% discount  -59: Distinct procedural service on the same day  Separate session

 Case 3 › 25 y/o patient falls from motorcycle › R distal radius displaced intra-artic fx › Manipulation performed in ED for preliminary stabilization › 5 days later, to OR  ORIF

 Case 3 › Code set / Wrist pain / outpt consult, with decision for surgery / 25605Closed tx radius with manip in ED, with plan for surgery / Open tx radius in OR, 5 days later  -58: Staged or related procedure  Planned prospectively  Subsequent procedure more extensive

 Case 4 › A 31-year-old carpenter, new patient in your clinic. › Exploration 3 days later revealed  Flexor tendon to his index finger in “Zone 2” and another to his long finger “not in Zone 2”  Severed the ulnar digital nerve IF  Lac ulnar digital artery IF › You perform debridement of all nonviable tissue was performed with repair of both flexor tendons. The procedure also included repair of the digital artery and nerve with an operating microscope followed by a simple repair of the wounds overlying the tendon and neurovascular injuries. A short-arm splint was applied.

 Case 4 › Code set / 99203Complex lac / consultation / F1Repair blood vessel, direct; hand, finger / F1-51Repair, flexor tendon, in Zone / F2-51Repair, flexor tendon, not in Zone / F1-51Suture of digital nerve, hand or foot / Microsurgical techniques  Local anesthesia included  Repair of skin included  Splinting included

 Case 5 › 62 y/o diabetic female, had R carpal tunnel surgery last month › Presents with new L LF/RF triggering › Patient seen in clinic during post-op period › Injections of LF/RF performed in clinic

 Case 5 › Code set / Outpt established pt; new problem, minor procedure / F2Injection LF tendon sheath / F3Injection RF tendon sheath  -24: Unrelated E/M service during post-op  -25: Significant E/M on same day of surgery  -79: Unrelated procedure in the post-op period  -F2: L LF  -F3: L RF

 Case 6 › 28 y/o female, MVA, multiple trauma › Initial eval with Grade IIIA R humerus fx › Taken to OR for urgent I&D and plating › Further workup 2 days later revealed nondisplaced sacral zone 1 fx; closed treatment

 Case 6 › Code set / Complex open inj / outpt consult, decision for surgery / 24515Open tx of humerus fx / I&D of skin to bone for open fx / Closed tx of pelvic fx without manipulation  -51: Multiple procedure  -79 modifier: Unrelated procedure during post-op  No fee reduction  Global period for humerus and pelvis separate

 Case 6 › If sacral fx and humerus treated on same day: › Code set Outpt consult, decision for surgery 24515Open tx of humerus fx I&D of skin to bone for open fx Closed tx of pelvic fx without manipulation  -51: Multiple procedure  50% fee reduction

 Terminology  Code Organization  Special Codes  Modifiers  Case Examples  Tips for Op Report Dictation

 Pre- and post-op diagnosis › Use ICD-9 terminology  Procedure › Use CPT language › Each procedure with corresponding diagnosis  Indications for surgery › Pt age › Reason for surgery › Previous related surgery

 Findings › Include things such as  Length of wound, size of skin graft  Extensiveness of surgery (for modifier -22)  Details › One-to-one correlation with listed procedures › Separate into paragraphs  Plan › Facilitates post-op care › Allows future use of -58 modifier

 Global service concept  Code organization › Body part › Category  Diagnosis :: Procedure  Documentation to justify EVERY code › Paragraph breakdown  Code every surgery, immediately