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

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

4.  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)

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

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

7.  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

8.  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

9.  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

10.  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

11.  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

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

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

14.  Sections › 10000 Skin and nails › 20000 Orthopaedic › 30000 Vascular › 60000 Neurosurgery › 90000 Medicine (includes wound care)

15.  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

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

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

18.  Symbols Ø Modifier -51 exempt + Add-on code 64831 Suture of digital nerve + 64832 each additional nerve + 69990 use of operative microscope ▲ Revised code ● New code * Service includes surgical procedure only * 20550 Injections; tendon sheath

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

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

21.  Femur IMN -22

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

23.  Femur IMN -53

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

25.  ORIF  I&D -51  Ulnar neuroplasty -51-59

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

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

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

29.  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

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

31.  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

32.  -22: Unusual procedural services › Scarring, bleeding, obesity, etc. › 25% fee increase › Must quantify extent of complexity

33.  -50: Bilateral procedure › Payment is 150% of the single code  -51: Multiple procedures › Payment at 50% (100-50-50-50-50) › Doesn’t always apply; some codes are exempt Ø 51 modifier exempt codes + Add-on codes

34.  -53: Discontinued procedure › Surgery or anesthesia started, but case terminated due to certain circumstances

35.  -54: Surgical care only › Bills surgical portion of CPT  -55: Postoperative management only › Bills for post-op component of CPT

36.  -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

37.  -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

38.  -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

39.  -79: Unrelated procedure during post-op period › Make sure there is a new diagnosis › New global period established › Track both global periods separately

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

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

42.  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

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

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

45.  Case 1 › Code set 719.43 / 99244-57Wrist pain / outpt consult, with decision for surgery 813.20 / 25574Open tx R radius/ulna shaft fxs 813.20 / 25565-51-59Closed manipulation of L radius/ulna shaft fxs  -51: Multiple procedure  50% discount  59: Distinct procedural service on the same day  Separate site

46.  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

47.  Case 2 › Code set 884.10 / 99244-57Complex open wound / consult, decision for surgery 813.52 / 25605Closed tx radius with manip in ED 813.52 / 25620-59Open tx radius in OR 813.52 / 11012-51-59I&D of skin to bone assc with open fx  -51: Multiple procedure  50% discount  -59: Distinct procedural service on the same day  Separate session

48.  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

49.  Case 3 › Code set 719.43 / 99244-57Wrist pain / outpt consult, with decision for surgery 813.42 / 25605Closed tx radius with manip in ED, with plan for surgery 813.42 / 25620-58Open tx radius in OR, 5 days later  -58: Staged or related procedure  Planned prospectively  Subsequent procedure more extensive

50.  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.

51.  Case 4 › Code set 883.1 / 99203Complex lac / consultation 903.5 / 35207-F1Repair blood vessel, direct; hand, finger 883.2 / 26356-F1-51Repair, flexor tendon, in Zone 2 883.2 / 26350-F2-51Repair, flexor tendon, not in Zone 2 955.6 / 64831-F1-51Suture of digital nerve, hand or foot 955.6 / +69990Microsurgical techniques  Local anesthesia included  Repair of skin included  Splinting included

52.  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

53.  Case 5 › Code set 354.0 / 99214-24-25Outpt established pt; new problem, minor procedure 727.03 / 20550-79-F2Injection LF tendon sheath 727.03 / 20550-79-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

54.  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

55.  Case 6 › Code set 884.1 / 99245-57Complex open inj / outpt consult, decision for surgery 812.31 / 24515Open tx of humerus fx 812.31 / 11012-51I&D of skin to bone for open fx 808.43 / 27193-79Closed 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

56.  Case 6 › If sacral fx and humerus treated on same day: › Code set 99245-57Outpt consult, decision for surgery 24515Open tx of humerus fx 11012-51I&D of skin to bone for open fx 27193-51Closed tx of pelvic fx without manipulation  -51: Multiple procedure  50% fee reduction

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

58.  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

59.  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

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