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

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

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› 10000 Skin and nails› 20000 Orthopaedic› 30000 Vascular› 60000 Neurosurgery› 90000 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

SymbolsØ 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

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

-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% (100-50-50-50-50)› 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 2009 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

719.43 / 99244-57 Wrist pain / outpt consult, with decision for surgery

813.20 / 25574 Open tx R radius/ulna shaft fxs813.20 / 25565-51-59 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

884.10 / 99244-57 Complex open wound / consult, decision for surgery

813.52 / 25605 Closed tx radius with manip in ED813.52 / 25620-59 Open tx radius in OR813.52 / 11012-51-59 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

719.43 / 99244-57 Wrist pain / outpt consult, with decision for surgery

813.42 / 25605 Closed tx radius with manip in ED, with plan for surgery

813.42 / 25620-58 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

883.1 / 99203 Complex lac / consultation903.5 / 35207-F1 Repair blood vessel, direct; hand, finger883.2 / 26356-F1-51 Repair, flexor tendon, in Zone 2883.2 / 26350-F2-51 Repair, flexor tendon, not in Zone 2955.6 / 64831-F1-51 Suture of digital nerve, hand or foot955.6 / +69990 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

354.0 / 99214-24-25 Outpt established pt; new problem, minor procedure

727.03 / 20550-79-F2 Injection LF tendon sheath727.03 / 20550-79-F3 Injection 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

884.1 / 99245-57 Complex open inj / outpt consult, decision for surgery

812.31 / 24515 Open tx of humerus fx812.31 / 11012-51 I&D of skin to bone for open fx808.43 / 27193-79 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

99245-57 Outpt consult, decision for surgery24515 Open tx of humerus fx11012-51 I&D of skin to bone for open fx27193-51 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