“Coding is the most important business skill that an orthopaedic surgeon can learn and develop.” This statement is reiterated at almost every business in medicine meeting, seminar, or conference; yet, many surgeons consider the process of coding and charge capture an onerous endeavor. In short, coding is the method of systematically describing what we treat and how we treat it to be paid for services which we provide for our patients. Although coding can be challenging, it is rule based and manageable. The purpose of this article is to introduce the reader to the terminology, methodology, and techniques of coding in order to learn and develop effective and efficient process-related habits.
To discuss the subject of documentation adequately, it will be divided into Evaluation and Management (E&M) services (new and established patient visits and consultations) and surgical/procedural codes. E&M documentation has strict and specific criteria that determine the level of visit performed, including the location that the service is performed (physician office, emergency department, ambulatory surgery center, or hospital). Each E&M service has 3 key components: history, physical examination, and medical decision making. The guidelines for each of these areas are summarized in multiple sources, including the Current Procedural Terminology (CPT) codebook. The detail included in the note should match the level of E&M service reported. Reference to another professional's note can be made (if it is reviewed) for certain components of the history section. The reference should include the physician or physician extender's name and the date of the review. The physical examination must be performed and recorded by the individual reporting the visit. It is also recommended that the evaluation of laboratory and radiographic studies be documented in the medical decision-making portion of the surgeon's E&M note. Finally, the assessment and plan should be thoroughly summarized by the treating physician. This area of CPT coding is the most complex and involved. To perform it efficiently, time and effort are required to learn the essentials. Before starting practice, the basic premise and requirements of documentation should be studied. It is beneficial to use a “cheat sheet” with a condensed set of criteria for the different levels of E&M services. This sheet can be used during dictation of the encounter. After a period of time in practice, the surgeon should attend a coding course or seminar to further improve his E&M “coding competency.”
The operative note should be dictated immediately after surgery. It is the one piece of the patient's record in which the surgeon can summarize all of the important information including all relevant diagnoses [as these define the medical necessity for the service(s)], surgical procedures, intraoperative findings, and postoperative plan. The recommendation is to code the case, dictate, and submit the charges at the same time. This practice creates the most consistent method in each of these areas. Coding the case immediately before dictation allows for the use of CPT terminology in the operative note and provides the opportunity for early review of the operative note by the billing team. This leads to a timely submission of the charge. When performed correctly, this technique has proven to improve reimbursement.
The current system used for coding diagnoses is ICD-9-CM. It uses a 3, 4, or 5 digit number for a particular diagnosis, external cause, patient symptom, or sign. For example, the codes are 3 numbers followed by a decimal point and then 1 or 2 additional digits (ie, closed femoral shaft fracture = 821.01). The majority of orthopaedically related codes are found in 2 sections (Chapters 13 and 17). Some difficulties with the current system exist, many of which stem from its lack of specificity. In general, the design of the system is organized and relatively logical.
As of October 1, 2015, the United States will transition to ICD-10. This system has been used throughout the world for a varying number of years. The US version, ICD-10-CM, is much more specific than ICD-9-CM in its description of a particular diagnosis, external cause, symptom, or sign. The added specificity creates an increased level of complexity. ICD-10 codes are an alpha numeric combination of 3 to 7 digits. Most musculoskeletal diagnoses require all 7 characters. The level of clinical acumen necessary for accurate coding is much higher than has been needed for ICD-9. Physicians are basically required to be a part of the diagnosis coding process due to the increased documentation needed to match an ICD-10-CM code to a diagnosis. The codes are organized in a similar fashion to ICD-9 so that those most relevant to orthopaedics are found in 2 sections [Chapter 13 (M codes) and Chapter 19 (S codes)]. There is no doubt that the transition to ICD-10 will be difficult. Most people involved in healthcare have been preparing for implementation for the past few years. Surgeons can prepare by studying, documenting to the level required by ICD-10-CM, and employing the codes in advance of the implementation as well as working with their billing staff to create efficient processes for the transfer of information. The potential for a negative economic impact is immense (especially early after its official implementation) and the best way to minimize the negative effect is to be as facile with the new system as possible.
CPT is the system used to code for patient encounters (E&M services), nonoperative and operative treatment of patients, including patients with musculoskeletal conditions. Each code is 5 digits and has a specific verbiage associated with it (27814 = open treatment bimalleolar ankle fracture, includes internal fixation when performed). The codes for patient encounters are in the Evaluation & Management section of CPT codebook, as discussed previously.
The majority of CPT codes associated with orthopaedic surgery involve the operative procedures with which surgeons are familiar (eg, intramedullary nailing of the femur and ACL reconstruction), as well as codes that describe nonoperative treatment of certain conditions (eg, closed treatment of lateral malleolus fracture). Minor procedures, such as joint aspirations or injections, are also defined by a code. Each procedural code has an assigned period of time (global period) during which the surgeon is paid for a “package of care” (0, 10, or 90 days) and cannot charge an E&M code associated with the specific procedure. The global payment is further defined by dividing the CPT code into preoperative (10%), intraoperative (69%), and postoperative (21%) work representing components of the global package.
It is the recommendation of the author that the surgeon applies the appropriate CPT code(s) to the procedure and communicates them to his coding/billing staffs for oversight and eventual bill submission, rather than have a member of the billing staff “pick” the code.
A modifier is a 2-digit code that further defines a CPT code. Modifiers are used to communicate additional information to the payer and are employed for multiple reasons including but not limited to a return to the operating room for a related procedure or an E&M service that includes the decision for surgery. Modifiers are designed to be used with either an E&M or a procedure code. Memorizing the myriad of possible modifiers is difficult, but the surgeon should be familiar with all the different reasons that a modifier may be needed to complete a code. This knowledge should lead to better communication between the surgeon and his coding staff, allowing for more efficient code submission and higher reimbursement.
RELATIVE VALUE UNITS
A relative value unit (RVU) is a value assigned to each CPT code. The resource-based relative value scale was developed at Harvard School of Public Health. In 1992, the resource-based relative value scale became part of the Medicare provider payment schedule. A certain total RVU value is assigned to each CPT code. Each RVU value is comprised of multiple components that include provider work (wRVU), practice expense, and malpractice cost. A fourth component of the total RVU value is the geographic practice cost index (GPCI) that accounts for the varying cost of services in different locations across the United States. The RVUs for all of CPT are controlled and managed by the RVS Update Committee (RUC), which is a part of the AMA. The process of changing RVU values or adding new CPT codes is well defined and extremely complex. CMS and other payors multiply the RVU value by a conversion factor (set dollar amount) to arrive at the physician's payment.
The wRVU component is also now used in a variety of ways by physicians, groups, and health organizations. The wRVU value represents the amount of time and effort for the surgeon associated with a particular service or procedure (CPT code). Examples include primary total knee replacement (27447) = 20.72 wRVUs (38.92 total RVUs) and ORIF of a pilon fracture, tibia, and fibula (27828) = 18.43 wRVUs (37.09 total RVUs). The wRVU values are used by practices/organizations to gauge physician productivity. Based on a predetermined dollar amount assigned to each wRVU by the practice or organization, formulas can be designed to define overall salary, bonus above a baseline salary, or even distribution of profits in groups with multiple subspecialties.
EXAMPLE OF THE PROCESS
Scenario: Patient With a Femur Fracture From a Motor Vehicle Accident
The patient encounter occurs and a decision for surgery is made (Fig. 1). The surgeon supplies the ICD codes and the appropriate E&M code to the billing staff, either at the time of the encounter or after the procedure is completed. Using the appropriate codes when posting the case with the OR will aid the hospital with its billing process and prepare the surgeon for later charge submission. Immediately after completing the procedure, the primary surgeon codes the case, dictates, and then submits the codes to the billing staff. The authors use a collection of aids to make this process more efficient. At the appropriate locations, “cheat sheets” are available for the most common ICD and CPT codes. For further effectiveness, we subscribe to an electronic database (CodeX, aaos.org/product/productpage.cfm?code=05380) that allows even more specificity for code evaluation and submission. The coders then make sure that the documentation matches the code submission. If a discrepancy exists, early communication between the billing staff and the surgeon should lead to a quick resolution. The staff then sends the appropriate codes to the payor. Contracts with payors will usually stipulate a period of time for the payor to respond. The response will be in the form of an explanation of benefits or remittance advice form either with the payment or a reason for denial. If the claim is denied, the billing staff will need to rectify the problem and resubmit the claim. In the most successful practices, the reasons for denial will be reviewed with/by the surgeon to correct any recurring problems with claim submission or to educate the surgeon on how to better understand the relationship between documentation and coding.
The preceding article has attempted to present an introduction to the coding and billing process for orthopaedic surgeons. It should be noted that each of the steps discussed contains a myriad of components that become more evident with further involvement in the process. The bottom line is that the coding and billing process is not simply a “back office job.” It requires significant surgeon involvement to create more efficient and effective charge submissions and a higher collection rate for the practice.