1. Coding Tips for the
Orthopaedic Office
Lynn M. Anderanin, CPC,CPC-I, COSC
AHIMA ICD-10-CM Certified Trainer
2. Healthcare Information Services
(HIS)
HIS is a physician management company based in Chicago,
IL specializing in Revenue Cycle Management and Information
Technology.
HIS provides services for over 450 providers and has a
dedicated Orthopaedic Division.
HIS is dedicated to helping physicians maximize their
reimbursement revenue, lower overhead and enhance your
bottom line. HIS is an expert partner for increased
profitability for your Orthopaedic practice.
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3. Presenter - Lynn Anderanin
Lynn Anderanin, CPC,CPC-I,COSC is the Sr. Director Coding
Compliance and Education for Healthcare Information
Services (HIS). She has over 28 years experience in all areas
of the physician practice including Practice Administrator,
Billing Manager, and Director of Operations. Lynn’s
experience is primarily in the specialties of Orthopedics,
Rheumatology, and Hematology/Oncology.
She has been a speaker for many conferences, including the
AAPC National Conferences and Workshops, Community
Colleges, audio conferences, and Local Chapters.
Lynn became a CPC in 1993, and a Certified Instructor in
2002, and a Certified Orthopedic Surgery Coder in 2009.
Lynn is the founder of the first local Chapter of the AAPC in
Chicago, which is now 15 years old, and a former member of
the AAPC National Advisory Board as well as other Boards for
the AAPC.
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4. We will cover ………….
Reimbursement statistics
Insurance Issues
E/M visits
Visits and procedures
Injections
Global surgery period
Fracture treatment
Casting and supplies
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10. Insurance Issues
Insurance eligibility and verification of
benefits
Patients with deductibles/health savings
accounts
Workers compensation and liability claims
Accident Date Information
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11. Insurance Eligibility and
Verification of Benefits
Is the patient eligible on the date of service?
Does the patient have office benefit
coverage?
Are braces and supplies covered under the
patients plan?
Does the patient have a Medicare PPO?
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12. Workers Compensation and
Liability Claims
Is there authorization from the insurance to
see the patient?
What services are authorized?
Does the patient have a cap on coverage?
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14. Accident Date Information
Does the patient information form ask for
accident date information?
Is the accident date information entered to
show on the claim form?
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15. Part B National Summary
Data File
https://www.cms.gov/Research-Statistics-Data-and-
Systems/Files-for-Order/NonIdentifiableDataFiles/
PartBNationalSummaryDataFile.html
Ortho 20
Hand 40
http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/downloads/clm104c26.pdf
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16. Comparative Billing Report
Safeguard Services contracted in 2010
http://www.safeguard-servicesllc.com/cbr/
default.asp
E/M reports sent to providers June 4, 2012
Compares providers to their peers
CBR and other Data analysis support and
tracking by CMS
http://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Data-analysis/
index.html?redirect=/Data-analysis/
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19. What Level is it?
Always choose lowest
History Examination MDM common denominator
New patient- must use all 3
Problem Problem
Straightforward
criteria
Focused Focused
Established patient- need
Expanded Expanded only 2 of 3 criteria
Problem Problem Low
Focused Focused Answer:
New pt. – Level 2
Detailed Detailed Moderate
Established pt.-Level 4
Comprehensive Comprehensive High
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20. Average Established
Patient Levels
Level 4- Established patient with a new problem
Level 3- Current problem still being treated
Level 2- Problem resolved/stable and/or patient
discharged
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21. Coding By Time
Documentation Necessary
Record of total time of the visit as well as the time
spent in the specific counseling or coordination of
care activities.
The note must include a summary of the content of
the counseling that occurred.
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22. Content of Counseling Summary
Diagnostic results, impressions, and/or recommended
diagnostic studies
Prognosis
Risks and benefits of management (treatment) options
Instructions for management (treatment) and/or follow-
up
Importance of compliance with chosen management
(treatment) options
Risk factor reduction
Patient and family education
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24. Modifier 24
Modifier 24 indicates the physician
performed an unrelated E/M service during
the post-operative period
ICD-9-CM codes that clearly indicate the
reason for the encounter was unrelated to
surgical postoperative care may provide
sufficient documentation.
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25. Modifier 25
The Centers for Medicare & Medicaid Services
(CMS) has clarified the documentation
requirements and policy requirements for the use
of CPT modifier -25 used with E/M services.
Please refer to the Medicare Claims Processing
Manual, Publication 100-04,Chapter 12, Section
30.6.6, for revisions regarding the use of CPT
modifier -25.
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26. Modifier 25
Common Procedural Terminology (CPT)
modifier -25 identifies a significant,
separately identifiable evaluation and
management (E/M) service.
It should be used when the E/M service is
above and beyond the usual pre- and
postoperative work of a procedure with a
global fee period performed on the same
day as the E/M service.
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27. Modifier 25
Different diagnoses are not required for
reporting the E/M service on the same date as
the procedure or other service with a global fee
period. Modifier -25 is added to the E/M code
on the claim.
Both the medically necessary E/M service and
the procedure must be appropriately and
sufficiently documented by the physician or
qualified NPP in the patient’s medical record to
support the need for Modifier -25 on the claim
for these services, even though the
documentation is not required to be submitted
with the claim.
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28. Modifier 57
Carriers pay for an evaluation and management
service on the day of or on the day before a
procedure with a 90-day global surgical period if
the physician uses CPT modifier “-57” to indicate
that the service resulted in the decision to perform
the procedure. Carriers may not pay for an
evaluation and management service billed with the
CPT modifier “-57” if it was provided on the day of
or the day before a procedure with a 0 or 10-day
global surgical period.
Medicare Claims Processing Manual, Chapter 12
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29. Postoperative Days
90 days is 90 days, not 3 months.
Verify that your carriers are following
Medicare postoperative day assignments
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30. Minor Surgery Example
To determine the global period for minor
procedures, carriers count the day of surgery and
the appropriate number of days immediately
following the date of surgery.
EXAMPLE:
Procedure with 10 follow-up days:
Date of surgery - January 5
Last day of postoperative period - January 15
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31. Major Surgery Example
To determine the global period for major surgeries,
carriers count 1 day immediately before the day of
surgery, the day of surgery, and the 90 days
immediately following the day of surgery.
EXAMPLE:
Date of surgery - January 5
Preoperative period - January 4
Last day of postoperative period - April 5
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32. Injections
There are many different types of injections
Joint Injections
20600- Small Joints
20605- Medium Joints
20610- Large joints
27096- Sacroiliac Joint
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33. More Injections
Tendon Injections
20550- Tendon Sheath
20551- Tendon origin/insertion
Trigger Point(muscle) Injections
20552- 1 to 2 muscles
20553- 3 or more muscles
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34. Miscellaneous Injections
Carpal Tunnel
20526
Xiaflex for Dupuytren’s Contracture
20527 (26341 for manipulation next day)
Ganglion cyst(s)
20612
Bone Cyst(s)
20615
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35. Normally Not Billed Separately
Syringes, needles
Bandages
Local Anesthesia(e.g. lidocaine,marcaine)
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36. Closed Treatment vs. Visits
AAOS Now-July 2008-
http://www.aaos.org/news/aaosnow/jul08/
managing2.asp
Physician has the option global or itemized
Closed treatment should not be billed by
ED physician
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38. Casting
CPT Guidelines State:
The services listed below include the
application and removal of the first
cast or traction device only.
Subsequent replacement of cast and/
or traction device may require an
additional listing.
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39. Casting Tips
Append modifier 58 to casting within the global
period of a procedure
If a procedure is performed, the initial cast is
included, however the supplies can be billed using
HCPCS codes A4580-A4590, or Q4001-Q4050.
MedLearn Matters with current casting
reimbursement for Medicare
http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads//MM7628.pdf
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40. Other Casting Codes
29700-29715- removal of casts if applied
by another physician
29730- windowing of cast
29740-29750- wedging of casts
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42. Supplies and Braces
Codes found in HCPCS manual
Separate provider number for Medicare
See Part A carrier in your jurisdiction
Fee schedule lists carrier responsible/fees by states
http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-
Schedule.html
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43. Special Alert
L3660, L3670, L3675 we deleted 12/31/2010
Then this was rescinded, and these codes are still
valid.
CMS MLN Matters® MM7300
http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/
MM7300.pdf
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44. Improve Profitability
with HIS
HIS is a full service Physician Management organization
offering expert services in Revenue Cycle Management,
EHR, Consulting and IT services.
Expert Coding consultation, Coding Certification
(including ICD-10), training, audits, assessments, etc.
HIS typically can increase your reimbursements by
10% or more.
Call HIS to see how we can improve your reimbursements,
lower overhead and boost overall profitability. 1-855-RING-
HIS
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45. RCM plus EHR
More Orthopedics are using SRS than any other EHR in
the country!
Bundled service: SRS-EHR and HIS's Revenue Cycle
Management Services together
Mitigates the up-front costs associated with the software,
hardware and implementation of an EHR purchase.
HIS will amortize the hardware and software costs into
HIS’ monthly service fee... allowing you to enjoy the
benefits and costs savings with zero capital out-lay.
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46. Contact HIS
Andy Salmen
Business Development
847-720-7007
asalmen@healthinfoservice.com
Lynn Anderanin
Senior Director of Coding Education and Compliance
847-720-7090
LAnderanin@healthinfoservice.com
WWW.HealthInfoService.com
1-855-RING-HIS
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