Principles of Coding Presentation

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

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
› 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


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
Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Patient had morbid obesity, and femur nailing
took twice as long

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

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

Open elbow fracture with ulnar nerve injury,
undergoing ORIF and I&D
ORIF
 I&D -51
 Ulnar neuroplasty -51-59


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% (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 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
719.43 / 99244-57
813.20 / 25574
813.20 / 25565-51-59
Wrist pain / outpt consult, with decision
for surgery
Open 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
884.10 / 99244-57
813.52 / 25605
813.52 / 25620-59
813.52 / 11012-51-59
Complex open wound / consult, decision
for surgery
Closed 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
719.43 / 99244-57
813.42 / 25605
813.42 / 25620-58
Wrist pain / outpt consult, with decision
for surgery
Closed 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
883.1 / 99203
903.5 / 35207-F1
883.2 / 26356-F1-51
883.2 / 26350-F2-51
955.6 / 64831-F1-51
955.6 / +69990
Complex lac / consultation
Repair blood vessel, direct; hand, finger
Repair, flexor tendon, in Zone 2
Repair, flexor tendon, not in Zone 2
Suture 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
354.0 / 99214-24-25
727.03 / 20550-79-F2
727.03 / 20550-79-F3





Outpt established pt; new problem, minor
procedure
Injection LF tendon sheath
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
812.31 / 24515
812.31 / 11012-51
808.43 / 27193-79
Complex open inj / outpt consult, decision
for surgery
Open 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
99245-57
24515
11012-51
27193-51
Outpt consult, decision for surgery
Open 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

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