Coding and reimbursement in arthroscopic surgery

Coding and Reimbursement in Arthroscopic Surgery

William R. Beach, M.D., John Ritchie, M.D., and Jack M. Bert, M.D.

OVERVIEW OF ECONOMIC ISSUESAFFECTING ARTHROSCOPIC SURGEONS

William R. Beach, M.D.

As an introduction, first let us legitimize the inclu-sion of information on coding and reimburse-

ment in our association’s periodic publication. The“Arthroscopy Journal” is first and foremost an educa-tional tool for the Arthroscopy Association of NorthAmerica and its members. Coding has become one ofthe most challenging parts of our daily practice. Keep-ing pace with the many changes in surgical and eval-uation and management coding requires both interestand diligence. Therefore coding has become an area ofintense interest and is mandatory for inclusion into oureducational programs. Second, coding has becomesynonymous with reimbursement. Our ability to effec-tively and efficiently care for patients is dependent onour success as business people. The safe and satisfac-tory execution of patient care requires many medicaland non-medical personnel. Recruitment and mainte-nance of these health care professionals is also costly.And lastly, incorrect coding places us in personal andprofessional jeopardy. The Health Care Finance Ad-ministration (HCFA) has made the investigation andprosecution of Medicare fraud an obvious priority.This reality propels coding into a new and heightenedlevel of importance.

Since the relevance of the subject has been estab-lished let us define the major parties involved in the“regulatory” side of medicine. First and foremost isthe Health Care Finance Administration (HCFA), thelargest consumer of health care services and theagency responsible for administration and regulationof government policy for Medicaid and Medicare.

A distant second in importance and influence in med-ical regulation is the American Medical Association(AMA). The AMA maintains its dominance as thenon-governmental leader of medical regulation be-cause of its representation of a large number of phy-sicians and its ownership of Common ProceduralTerminology (CPT). After HCFA and the AMA arethe large medical societies whose members makeup the AMA. The Academy of Orthopedic Surgeons(AAOS) is one of these societies. Smaller subspecialtyassociations, such as the Arthroscopy Association ofNorth America (AANA), are represented in theAAOS. AANA is dependent on its involvement in theAAOS for many of its regulatory requests and func-tions.

HCFA’s dominance in every facet of health care isprocedurally rooted. In the late 1980’s and early1990’s a Harvard University study set out with thegoal of comparing all medical “encounters,” surgicaland non-surgical. In 1992, HCFA began to pay forservices based on the new resource-based relativevalue scale (RBRVS). This essentially ended the pre-vious system of “usual and customary” charges. TheRBRVS is broken down into three categories: physi-cian work, practice expense, and professional liability.The payments are approximately 55%, 42% and 3%respectively (e.g., when you receive a $100 MedicareHCFA payment for surgical services provided you areactually being paid $55 for the patient’s surgery, $42for your practices’ expenses for caring for that patient,and $3 for the malpractice exposure for that patient).Logical questions would be how were the relativevalues determined, are the relative values reviewed,and who is responsible for maintaining the system andhierarchy.

First, the RVU’s were established using detailedand lengthy questionnaires. Having reviewed the pro-posed methodologies for collecting such information,the author was overwhelmed by the scope and thedifficulty in verifying the voluminous documentationinvolved in such a project. The reality is the values areset.

Address correspondence to William R. Beach, M.D., TuckahoeOrthopaedics, PO Box 71690, Richmond, VA 23255, U.S.A.

© 2002 by the Arthroscopy Association of North America0749-8063/02/1802-0109$35.00/0doi:10.1053/jars.2002.31802

96 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 2 (February, Suppl 1), 2002: pp 96-121

Second, the United States Congress mandated thatthe RVU’s must be reviewed every five years. HCFAis currently in the process of re-evaluating each pro-cedure and its relative value. HCFA is greatly assistedby the AMA in this endeavor but is in no way obli-gated to accept any recommendation made by anyindependent body on the value of any service.

Third, the AMA, as will be reviewed later, is theowner of the copyright for CPT. RVU’s are assignedto most procedures with a CPT code number. There-fore, RVU’s are maintained by HCFA on CPT codesmaintained by the AMA.

To review the politics of coding we will review theapplication request process CPT codes. The AMAdevised Common Procedural Terminology (CPT) in1966. CPT is a comprehensive classification and no-menclature for accurately identifying procedures andservices performed by physicians and other healthcare professionals. The purpose of CPT is to providea uniform language that accurately describes medical,surgical, and diagnostic services and thereby serves asan effective means for reliable nationwide communi-cation among physicians, patients, and third parties.1

CPT is continuously revised and therefore requires“maintenance.” An AMA committee known as theCPT Editorial Panel provides this “maintenance.” TheEditorial Panel is made up of 16 physicians (11 aredetermined by the Board of Trustees of the AMA, 1 isthe Health Care Professional Advisory Committee co-chairman, and 1 each is nominated by Blue Cross andBlue Shield, the Insurance Association of America,the Health Care Finance Administration, and theAmerican Hospital Association).

Supporting the Editorial Panel is the CPT AdvisoryCommittee. This committee is comprised of members,primarily physicians, nominated by the national spe-cialty societies represented in the AMA House ofDelegates. They act as a resource for the EditorialPanel by giving advice on coding, providing docu-mentation on procedural appropriateness, suggestingCPT revisions, developing technical educational ma-terial, and promoting and educating the AMA mem-bership on CPT issues.1

This will illustrate the complex working relation-ship between the medical societies, the AMA, andHCFA (HCFA receives its mandate from the federalgovernment). Requesting a new CPT code or chang-ing an existing code follows a clearly defined process.First, a requestor must carefully consider the issuesinvolved in requesting or changing a particular code.These issues include: (1) is the new code consistentwith the other codes in the category of codes? (2) Is

the new code a duplication of a pre-existing code? and(3) is there a combination of codes that would achievethe same coding goal? Once the requestor has accom-plished this and believes a new code or change isappropriate then a “Coding Change Request Form” isobtained from the AMA. The success of the entirerequest process is critically related to the accuracy andcompleteness of the request form. Instructions pro-vided in this form include “indicate the specific rea-sons why this code or coding change is necessary,”“specify the recommended terminology for the pro-posed code,” and “provide a clinical vignette whichdescribes the typical patient and a description of theprocedure.” The clinical vignette will accompany thisrequest for the life of the request and therefore, aconcise specific description of the patient and service(procedure) must be scripted. Currently the requestform is ten pages and 26 questions in length. After therequest is complete it is sent to the AMA where thestaff reviews the form and determines if this questionhas already been considered. If it has been previouslyconsidered then the AMA will send the requestor aresponse noting the Editorial Panel’s previous deci-sion and the correct coding procedure. If the staff orthe advisors of the CPT Advisory Committee mem-bers either agree with the coding change or if two ormore disagree on the question then it will be referredto the CPT Editorial Panel for consideration. The CPTAdvisory staff will then further investigate and re-search the procedure or service. It is important for therequestor and the requesting society to be very activeat this point to provide appropriate data supporting theefficacy of the procedure. This is a crucial hurdle fora CPT code request. A CPT code request has almostno chance of being accepted without the support of the“sponsoring” medical society. For example, an arthro-scopic code request generated by AANAmusthavethe support of the AAOS. The AAOS has many sub-specialties vying for the influence required to propel alimited number of codes acceptance at any given time.The AAOS CPT Coding Committee reviews volumesof material including the CPT coding requests thathave been either submitted to it directly by AAOSmembers, or requests that have been submitted to theAMA and referred back to the AAOS for its endorse-ment. This “rerouting” mandates AAOS support on allcoding issues related to orthopedics and the musculo-skeletal system.

The AMA Editorial Panel can take three actions onthe code request: (1) add a new or revise an existingcode, (2) table an item for further information anddiscussion, or (3) reject the item. If a new code is

97CODING AND REIMBURSEMENT

granted, it will be one of three types, category I, II, orIII. Category I codes are the “working” codes of CPT.These codes will be given a 5-digit CPT number, bereferred to the AMA/Specialty RVS Update Commit-tee (RUC) for an RVU assignment, and be listed in thenext edition of CPT. Category II codes are “perfor-mance measurement” codes and are “intended to fa-cilitate data collection by coding certain servicesand/or test results that are agreed upon as contributingto the positive health outcomes and quality patientcare.”1 These services are currently included in theEvaluation and Management (E/M) guidelines. Cate-gory III codes are “emerging technology” codes. TheAMA has stated that this is an avenue for data collec-tion on procedures that are new or have been previ-ously coded as unlisted procedures. This will allowphysicians, HCFA, and third parties to separate theunlisted procedure codes and determine the numberand types of procedures being performed that cur-rently do not have category I CPT codes. Assignmentof this code in no way implies the procedure is exper-imental but does mandate that there is ongoing clinicaldata collection on the procedure. These procedurallistings will be assigned an alphanumeric identifierwith a letter being the last character (ex. 1234A) andwill also not be referred to the RUC for valuation.Examples of category III codes are meniscal and os-teochondral transplants, other than for the treatment ofosteochondritis dissecans (OCD).

The above is a review of the mechanics of CPTcoding. Much more interesting philosophically are themotives and the process through which the UnitedStates government has taken complete control ofhealth care and its costs. As will be obvious, the planwas/is as perfect in its conception and execution, as itis unfair and un-American in its creations. First, theblueprint to “control” the cost of medical care in theUnited States must have been conceived in the mid orlate 1980’s. The reason to control medical cost wasthe increasing percentage of the gross national productbeing consumed by medical care. The previous notedHarvard University study provided the comparisonand ranking of all medical procedures. This rankingwas a mandatory and early building block in theprocess. A second major event was the Balanced Bud-get Act of 1997. This essentially froze the availablefunds to provide health care for Medicare. WithRVU’s well established as the process for medicalpayment and a defined, relatively static amount ofmoney, true valuation and aggressive cost contain-ment was not only possible but also logical. How

could a single industry be chosen and targeted? Phy-sicians are by nature and necessity independent inthinking and action. The government has mandatedthis by disallowing physicians to “conspire” with oneanother in regards to pricing and has made unioniza-tion impractical. Physicians, besides the very fewwell-intentioned physicians intensely involved in theregulatory process, dislike the topic of coding andbureaucracy. Education for young physicians in cod-ing and regulation is almost non-existent and medicaland specialty societies have been slow if not reluctantto include coding in their meeting curricula.

Is there any precedence for this level of governmen-tal intrusions into private industry? There is no indus-try that has been as negatively affected and thoroughlyinspected as health care. One can only imagine anequivalent situation where an industry, such as thedefense industry, is given a task, informed of the levelof service required, supplied with defined penalties ifthe level is not attained, informed of changes in policywith seemingly little or no input, being placed inconstant jeopardy of felony fraud for not following thechanging rules, being told exactly how much you willbe reimbursed (no matter what your expenses andwithout reasonable increases in cost of services) andlastly, no matter how willing you are to help provideyour services (your intellectual property) to the elderlyand less fortunate, that the government will share itscost saving scheme with every third party payer be-cause it is a matter of public record. Clearly, thisun-American treatment of an industry is clearly un-precedented and unethical.

What is our recourse? Education. The education ofour members, our staffs, and most importantly, ourpatients is tantamount in this “conflict.” The exposureof this injustice is our responsibility. These policieswill adversely affect our patients and the acknowl-edgement of this importance requires a commitmentfrom each physician on their behalf. We must engagethe “game” defined by HCFA policy, learn its nu-ances, and use it accurately as we move to fundamen-tally convert it to one that is user friendly and patientkind. Join the leadership of AANA and get involved inhealth care regulatory issues. We need your help andinterest.

Reference

1. CPT. An Overview. American Medical Association. Division ofPayment Programs. Department of Coding and Nomenclature,1997.

98 W. R. BEACH ET AL.

E&M DOCUMENTATION: OPPRESSION OR OPPORTUNITY

John Ritchie, M.D.

How could the same medical record be used to successfully defend yourclinical decisions in a malpractice trial and also be used by an insurance

auditor to put you in jail for fraud? This is the reality of compliance. For years,the message from office managers, consultants, and the AAOS has been thesame . . . learn to put more bullets in your dictation!

So how has a group of 14,000 intelligent orthopaedic surgeons not respondedto this message? The simple answer is the 1997 HCFA Guidelines are tooconfusing to understand, remember, and put into use for busy orthopaedicpractice. Recently there was hope that these rules would change, but this hopehas vanished for the foreseeable future.

It helps to see E&M Documentation and Coding as opportunity rather thanoppression. Medicare will soon reduce your fees by 5%, and that fact isbeyond your control. Experts estimate that you canlegitimately increaserevenue by 25% with improved coding, and this you can control. Theincrease is not through fraud, trickery, or deceit. It comes from eliminat-ing the rampant practice of undercoding, which is theintentional reduc-tion of the office visit level by the orthopaedic surgeon out of fear of anaudit.

The irony of undercoding is that even though charges are voluntarily reduced,there may still be an insufficient number of bullets in the dictation to supporteven this reduced charge. Therefore, the orthopedist can still face the risk ofaudit risk!

So why is it seemingly impossible to get enough bullets into the dictation?The reasons are:

1) We do not document what we see, do, and say in our patient encounters.2) We did not know the rules of coding.

In the first section of this article, the 1997 HCFA Guidelines will be revieweddemonstrating how the Key Components are used to determine the level ofoffice visit charge. The second section, beginning on page 10, will explain theCompliance System developed by the author to simplify the process of docu-mentation to make Compliance a realistic goal and reverse the trend towardundercoding.

E&M Documentation: The Rules

Ignorance of the rules is not a result of poor teaching. For years, codingpioneers such as Blair Filler, M.D., Robert Haralson, M.D., M.B.A., MelvinFriedman, M.D., Brian Hotchkiss, M.D., as well as past and present mem-bers of The AAOS Coding Committee, have worked to assist in the under-standing of E&M Coding based on the 1997 Guidelines. TheAAOS Guide toCPT Coding,upon which much of this article is based, is the best review ofE&M Coding available, and should be required reading for all OrthopaedicSurgeons.

E&M Documentation: The Basics

Much of the information is presented in outline format since it is familiarmaterial.


Definitions:

A. Patient Types:1. New Patients—New to the practice or no visit to the practice for 3 years2. Established Patients—all others

(note: consultations can be performed on new or established patients)B. Office or Outpatient Visit Types:Abbreviations

1. New Patient Visit (5 levels (9920_)) N1, N2, N3, N4 and N52. Established Patient Visit (5 levels (9921_)) E1, E2, E3, E4 and E53. Consultations (5 levels (9924_)) C1, C2, C3, C4 and C5

C. Consultations:The rules concerning consultation have been confusing for both the physician

and the auditor. To make matters worse, every meeting attended and everyconsultant hired seems to give a different version of what can be called aconsult.

There are two concepts concerning consults that have to be understood beforea comfort level for charging for a consultation can be obtained: (1) The criteriafor consultation, and (2) The definition of transfer of care.

Criteria for Consultation: (1) The consultation must be requested by aphysician or “appropriate source” whose opinion or advice regarding evaluationand/or management is requested. Clarifications to this statement have included:“Appropriate source” is currently defined as MD, DO, dentists, podiatrists,optometrists, chiropractors, physicians assistants, nurse practitioners, clinicalnurse specialists, clinical social workers and clinical psychologists. Note: notphysical therapists. Consults can be performed by orthopaedic surgeons in thesame group who have different areas of expertise and desire opinions or advicefrom a partner. The ER physician’s role in requesting consultations can vary. Ifconsultation is requested in the ER, than the ER physician is asking for anopinion about evaluation and management and may use that opinion to treat thepatient. If the ER physician arranges for evaluation in your office at a later date,then your opinion will not be used by the ER physician who no longerparticipates in the care of the patient, so the criteria for consultation are not met.

(2) The consultant may initiate treatment (i.e.,after your consultation hasoccurred, treatment can start immediately).

(3) The record must document the request for consultation and the need forconsultation. In addition, the consultant’s opinion, and any services ordered orperformed must be documented in the record and communicated to the request-ing physician (or appropriate source). Clarifications include: The request forconsultation can be verbal (the most common) or written. In either case, it is bestto state in your documentation who requested the consultation and why it wasrequested (e.g., “A consultation was performed at the request of Dr. Smith forleft knee pain.”) Since most office consultations are arranged through theappointment secretaries in each office, it is important that the orthopaedic officestrack these requests to ensure that appropriate consultations arelegitimatelyperformed and billed. The record can be a common record as found in thehospital setting (Emergency Room), multi-specialty clinics, or a single Ortho-paedic practice (where one partner consults another). In these situations, aseparate report, other than the common record documentation is not required(but can still be performed for completeness).

Transfer of Care: This concept has confused the understanding of when itis appropriate to charge for a consultation. Two situations can occurafter aconsultation. (1) The patient returns to the requesting physician with recom-


mended treatment for the requesting physician to initiate treatment or (2) theconsulting physician begins treatment. Medicare will pay for consultation evenif treatment is initiated “unless a transfer of care occurs.” This is where theconfusion originates. The wording of the instruction is as follows: “a transfer ofcare occurs when the referring physician transfers the responsibility for thepatient’s complete care to the receiving physician at the time of referral (i.e.,before the consultant even sees the patient)and the receiving physician (i.e. theorthopaedic surgeon) documents approval of carein advance.” For nearly allorthopaedic patients, transfer of care never occurs. Even if transfer of care (fullor partial) did occur, it would occur after the consultation and the consultationfee could still be charged.

An example of absence of transfer of care is as follows: a familypractitioner suspects a meniscus tear and requests a consultation. Theorthopaedic surgeon evaluates the patient and makes the diagnosis of ameniscus tear and subsequently performs an arthroscopy. The patient thenreturns to the family practitioner at the completion of care. Total care of thepatient has not been transferred since the patient will return to the familypractitioner for non-orthopaedic care, not to the orthopaedic surgeon. Note:Take a close look at the wording on the forms you receive from HMO’s. Itis usually a request forconsultationand the word “consultation” is on theform! Why not charge a consultation?

Types of Consultations: (5 levels in each category). (1)Office or outpatient:(9924_0) E&M services provided at the request of another physician or appro-priate source (see above) performed in the outpatient setting, including the ER.This includes 2nd opinions requested by another physician but not by a patient.(2) Inpatient: (9925_) Similar service performed in the inpatient setting. (3)Confirmatory:(9927_) E&M services requested by a patient (2nd opinion) or bya 3rd party (insurance company) to determine the appropriateness of surgicaltreatment or testing.

Preop Consultations: These are outpatient consultations that can be requestedfrom the patient’s family physician or other medical consultant for pre-operativeevaluation, but not for “clearance for surgery.” If there is a specific medicalcondition or concern over certain medications (i.e., coumadin) that needsevaluation prior to surgery, then consultation is appropriate. Routine preophistory and physical examinations are included in the global fee and are notseparately reimbursed. This includes those H&Ps required by the hospital orsurgery center. These H&Ps are considered part of the global fee and will notbe reimbursed by Medicare.

E&M Documentation: Does Your Practice Need Improvement?

Take this Compliance Self-Test. If you answer yes to any of the questions,then you should continue to read this entire article.

Compliance Self-Test

1) Your practice has never had a successful Compliance Audit (or worse,has never done an audit). h Y h N

2) You havecharged a New Patient Level 4 Visit (N4) but you havenever documented an examination of lymph nodes or coordination andbalance. h Y h N

3) You don’t charge a New Patient Level 4 Visit (N4) when you knowyou should because you’re afraid you won’t dictate enough bullets in therecord. h Y h N


Determining Visit Level:

There are 7 components that can be used to determine level of service. Theorthopaedic surgeon will need to be familiar with 5 of them. The key compo-nents will be reviewed in detail. See reference 1, 2 and 3 for detailed discussionof the contributory components.

A. Key Components1) History (CC, HPI, ROS, PH, FH and SH)2) Physical Examination: Two options are available for the content of

the exam:a. Multi-Specialty Exam (used chiefly on inpatients)b. Single Specialty Musculoskeletal Exam

1. Constitutional2. Cardiovascular3. Lymph4. Musculoskeletal5. Skin6. Neuro-Psych

3) Medical Decision Making(MDM)a. Diagnosis Optionsb. Complexity of Datac. Risk

B. Contributory Components4) Nature of Presenting Problem:In essence, this means that you can’t

charge a level 5 visit for a sprained ankle.5) Time:Consider using it for pre-op visits where over 50% of the visit

is for counseling.

Key Components: The New “SOAP” Format

The key components are the insurance company’s equivalent of the “SOAP”format (Subjective Objective Assessment and Plan) that we learned in medicalschool. The SOAP format was used to organize our thinking, to reach a correctdiagnosis, and to convey our treatment plan to our medical colleagues. We stillutilize these important tasks, but in addition, we need to use the medical recordto prove to the insurance companies that we did enough “work” to justify ourcharges. This does not mean we need to do more work; we just need todocument the work that we alreadyperform,but oftendo not dictateinto themedical record.

Consider using a new “SOAP” format: “SayOr AbortPayment.” We need todictate (or say) all of our thoughts, observations, findings and recommendationsinto the record to correctly reflect the work that we perform in the evaluationand management of patients. The key components help us organize that taskthrough an inventory system of bullets to test compliance.

The biggest challenge is that Compliance is a Pass/Fail test; if you miss onebullet, even though you correctly documented 50 other bullets, you still riskbeing accused of fraud. The answer is to “Say” more in the dictations byunderstanding the requirements and by possibly developing and using tools andtemplates to help organize your dictations as explained later in this article.

Key Components: History

History elements: every history will be audited against the following ele-ments.


A) Chief Complaint (CC):every record must have one. It is often missing infollow-up notes. It describes the symptoms, problem, or condition requiringevaluation (e.g., left knee pain).

B) History of Present Illness (HPI):elements used to chronologically describethe illness or any changes in symptoms. The following elements (bullets)are used to audit the HPI.

1. Location 3. Severity 5. Context 7. Associated signs2. Quality 4. Timing 6. Modifying Factors and symptoms

C) Review of Systems (ROS)An inventory of questions asked to patientsconcerningsymptoms.Most surgeons use a medical questionnaire form toobtain these bullets and either refer to the form in their dictation orre-dictate the appropriate bullets into the record.Avoid the following common problems with documentation using a form:a. the form does not include enough systems for the higher level

exams (you should review 14 systems on the form and document10 systems in the record). If your form only has 10 items (includ-ing Musculoskeletal [MS]) and the auditor determines that theMS symptom review is really an HPI element, then you will onlyhave 9 systems documented. Revise the form to include all 14systems.

b. the form containsdiseases(i.e., heart attack, which is a Past Historyelement) instead ofsymptoms(i.e., chest pain), and often does notqualify in the eyes of the auditor.

c. The form is not signed by the physician and referred to in the notes.d. There is a no comment section on the form to expand on positive or

pertinent negative aspects of the ROS, or these areas are not expandedon at all.

The following are the elements of a system review as identified by CPT.(Abbreviations are made by the author for spacing; refer to CPT for exactwording.)

1. Constitutional 4. Cardiovascular 7. GU 10. Neuro 13. Heme2. Eyes 5. Respiratory 8. MuscSkel 11. Psych 14. Allergy3. ENT 6. GI 9. Skin 12. Endo

D) Past History (PH):An inquiry into prior illnesses, operations, injuries, andtheir treatment. A checklist is often used and is usually adequate as long asit is reviewed and signed by the physician. One statement is required fordocumentation.

E) Family History (FH):An inquiry concerning health status or cause of deathof family members, diseases related to HPI in family members, or heredi-tary diseases. One statement required for documentation.

F) Social History (SH):A review of past and current activities includingmarital status, jobs, alcohol, tobacco, drugs, education, and sexual history.One statement required for documentation.

The 1997 Guidelines use the term PFSH (or Past, Family, and Social History)to refer to these individual elements. Although this may help the auditor, it ishelpful to think of them independently for documentation purposes.


Choosing an Office Visit Level—History Key Component

To determine an office visit level using the 1997 HCFA Guidelines for theHistory “Key Component,” you must be able to master multiple tables ofinformation for the History (as well as the Physical Exam and MDM as seenbelow) and cross reference these tables to determine the level to charge. This iswhere much of the confusion exists. This cross referencing is easy for an auditorto perform where time is not crucial, but to expect that this can be done in theoffice setting for each patient seen seems like “Mission Impossible” withoutmastery of the Tables.

What makes this task even more difficult is that the actual 1997 HCFAGuidelines do not contain all the tables for conversion. You must cross referencethem against information contained in the Current Procedural Terminology(CPT 2001 Manual) to get complete instruction. Fortunately, much of thisinformation has been reorganized by the AAOS in theAAOS Guide to CPTCodingmentioned earlier and is highly recommended.

The following table uses the HCFA terminology to illustrate the minimumrequirements for documentation for a New Patient Visit. Space does not allowfor a review of established patients.

Problem FocusExpanded

Problem Focused Detailed Comprehensive

CC Yes Yes Yes YesHPI Brief 1 bullet Brief 1 bullet Extended 4 bullets Extended 4 bulletsROS 0 Problem Pertinent

1 systemExtended 2

systemsComplete 10

systems*PH 0 0 Pertinent 1 bullet

from any of the3 areas

Complete 3 bullets.One fromeachof 3 areas

FH 0 0SH 0 0

*10 systems need to be documented individually or, if negative, a statement that “all othersnegative” is acceptable. A form that is reviewed and signed and is sufficient; however, the formshould “inquire about the system(s) directly related to the problem(s) identified in the HPI plus alladditional body systems.” This implies that the form must contain 10 systems for review.

The information in the table above must then be cross referenced to the tablebelow to determine the actual office level charge based on the History component.

N1(99201) N2 (99212)

N3(99203) N4 (99204) N5 (99205)

HistoryType

ProblemFocused

ExpandedProblem Focused Detailed Comprehensive Comprehensive

Key Components: Physical Exam

The Single Organ Musculoskeletal Exam is used in the office setting. Thecomponents of the Musculoskeletal Exam required fordocumentationare listedbelow. The physical exam elements that must beperformedare greater thanthose required todocument.Refer to the references at the end of this article forthat information.

The author has abbreviated some of the elements in the following chart. Theorder was rearranged from the original text by the author for clarification andspace considerations. Be sure to read the * notes in the chart.


Physical Exam Area Bullets Achieved

* 6 Body Areas (BA) are recognized for MSand Skin

11

1. Neck (and head)2. Spine (ribs and pelvis)3. RUE4. LUE5. RLE6. LLE

Exam of one joint per body area is adequatefor documentation.

Comprehensive level exams (N4, N5 and E5)require all 4 elements in 4 Body Areas (ieBA1, BA2, BA3, BA4) for both MS andskin. The clinical situation dictates whichBody Areas are chosen.

For all other exams, simply count totalbullets documented for affected bodyareas.

1. Constitutionala. 3 Vital Signs (measured)b. Appearance (one statement)

2. Musculoskeletal (MS)a. Gait and station 1b. Body Area (BA) Examination* BA1 BA2 BA3 BA4

1. Inspection/Palpation 1 42. Range of Motion3. Stability4. Muscle Exam

1 1 1 11 1 1 11 1 1 11 1 1 1

3. Skin 1 1 1 14. Cardiovascular

a. One statement about any item includingpulse, temperature, edema, tenderness,swelling, varicosities. 1

5. Neuro-Psycha. DTR’s and pathologic reflexes 1b. Sensation 1c. Coordination and Balance 1d. Orientation3 3 1e. Mood and Affect 1

6. Lymph (one area) 1Maximum number of bullets 30

To determine the type of Physical Exam performed, use the Table below.

ProblemFocused

ExpandedProblem Focused Detailed Comprehensive

Bullets 1 6 12 30

Choosing an Office Visit Level—Physical Exam Key Component

To determine the New Patient office level to charge based on the PhysicalExam, cross reference the Table above with the Table below.


N1(99201) N2 (99212)

N3(99203) N4 (99204) N5 (99205)

ExamType

ProblemFocused

ExpandedProblem Focused Detailed Comprehensive Comprehensive

Key Component—Medical Decision Making

This component is the most difficult to explain, but fortunately, is one of thestrongest areas of documentation for orthopaedic surgeons. Improvement incompliance results from simply documenting what has already been done duringthe exam. Many times elements are performed or observed during a patientencounter (i.e., gait), but unfortunately, rarely dictated. Use the redefined“SOAP” format and “say” more of the thought process used in analyzing theclinical situation to satisfy this requirement.

Medical Decision Making includes 3 areas. You have to achieve documen-tation in only 2 of the 3 areas to be compliant. The sequence of these areas wasre-organized from the original text so it is more in keeping with how we thinkand dictate. The first two areas are scored by total points. The last is moresubjective (for the surgeon and the auditor).

1) Amount and Complexity of Data to Review(“Data points,” usually x-Rays)

This includes ordering and interpreting x-rays as well as elements in the tablebelow. Improve this by documenting your review and summary of old recordsand any “curb-side” consults with partners in the office. This indicates to theauditor that the clinical situation was more difficult.

1.)* Interpret rad:2 points

3.) Review radreport:1 point

5.) Review report withperforming MD:1 point

7.) “Curb-side”consult: 2 points

2.) Order rad: 1 point 4.) Review labreport:1 point

6.) Review andsummarize oldrecords: 2 points

8.) Order old records:1 point

*rad 5 x-rays, MRI, CT, Nuclear Med Scan, Doppler etc.

To determine the score in this section, add the total points and refer toSummary Table on the next page.

2) Number of diagnosis or management options (Diagnosis points)

Achieve points for the diagnosis that is documented and whether the condi-tion is stable, improved, or worsening. Note that a new problem generates 3diagnosis points and achieves a moderate complexity level.

Column A CategoriesColumn BNumber x

Column CPoints

Column DScore

Self Limited or minor (stable, improved, worsening) Max5 2 1Established problem (stable or worsening) 1Established problem (worsening) 2New Problem, no additional workup planned Max 5 1 3New Problem, additional workup planned 4

To determine your score (Column D) multiply Column B by Column C, thensum Column D. Then apply those scores to the Summary Table below.


3) Risk of complications, morbidity, and mortality:This is the risk to thepatient associated with the diagnosis itself or the tests and treatmentrecommended. This section is difficult to explain; however as longas you document your thoughts, you usually will qualify. I have in-cluded an example for each level to give an idea of the requirements. Afull table is found at the end of the article and is also detailed in thereferences.

Minimal Low Moderate High

Risk Rx 5 Ace wrap Dx5 sprain Rx5 prescriptionDrug*Tx 5 scope inpatient withoutrisk factors

Tx 5 scope in patientwith risk factors

* includes issuing, changing or renewing prescriptions or dispensing samples.

Medical Decision Making—Putting it all Together

Once the Data point, Diagnosis point, and Risk assessment has been madeusing the tables above, the summary table listed below is used to complete thedetermination of Medical Decision Making.

Summary Table for MDM

Straightforward Low Complexity Moderate Complexity High Complexity

Data Points 1 2 3 4Diagnosis Points 1 2 3 4Risk Minimal Low Moderate High

Once the summary for MDM has been achieved, the level of New patientoffice charge is determined by one final table below. Remember that only 2of the 3 MDM elements need to be achieved to determine the final MDMlevel.

N1(99201)

N2(99212)

N3(99203) N4 (99204)

N3(99205)

MDMType

Straight-forward

Straight-forward Low Moderate High

E&M Documentation—Combining the Key Components

The orthopaedic surgeon must master and remember all of the 10 KeyComponent Tables reviewed above, and then refer to the final (I promise) Tablebelow to “Put it All Together.” It is expected that this process will be repeatedwith each patient seen in the office to determine a level of charge. Note: sincemany orthopaedic offices create an office charge prior to creating medical recorddocumentation, all the above tabulation must be done without referencing officenotes.


N1 99201 N2 99202 N3 99203 N4 99204 N5 99205

History ProblemFocused

ExpandedProblemFocused

Detailed Comprehensive Comprehensive

Exam ProblemFocused


Detailed Comprehensive Comprehensive

MDM ProblemFocused


Low Moderate High

Although beyond the scope of this article, there are additional tables that areused for established patients, consultations, and hospital E&M services (con-sultations and initial and subsequent hospital visits) for a total combination of 30visit types, all with their own criteria to remember.

Author’s Preferred Method: “KISS” With Tools and Templates

Three years ago, my 12-person orthopaedic group decided that one of thepartners had to learn coding to teach the rest of the group. I got the “shortstraw.” We were concerned about compliance and wanted to ensure that wewere not at risk for Medicare fraud. I spent hundreds of hours reading andre-reading the 1997 Guidelines, CPT books, and ICD-9 books and designingtools to help in coding. I was surprised how much I did not know, butquickly found that I could not remember all the rules and tables, let aloneteach them to my partners.

Eventually, I saw a simple pattern that allowed me to simplify the rulesand created a compliance tool to teach my partners how to become compli-ant. To make it even easier, I revised our Medical Questionnaire Forms (tofunction as History Templates), designed a Physical Exam Template, anddeveloped a new Superbill. Each of the changes were made to make it easierfor us to get the appropriate bullets into the dictation to reflect the work wewere actually performing, but not recording. Most recently, I created a seriesof 50 templates that allow us to dictate a few words yet have the transcrip-tionist type 2 or three sentences into the dictation that are chock full ofbullets. The templates let us create more text with appropriate bullets, but inless time than we needed to dictate “the old way.” By “keeping it simple,”the Keep It Simple Stupid (KISS) principle allowed all of the partners aswell as our physician assistants to rapidly increase their compliance usingthese tools and templates. Although we “said” more, there was actually areduction in the time it took to dictate. Once we were confident in ourcoding, we stopped undercoding and dramatically increased our codingrevenue . . . legitimately!

The following Table is an excerpt from the Coding Template that Ideveloped to explain Compliance to my partners and PAs. I was able tosimplify the concepts by removing the terms “problem focused,” “expand-ed problem focused,” “complete” and “comprehensive” etc. This table is agrid for the new patient coding rules, and summarizes the rules in the11 Tables described above. N1 refers to anewpatient level 1 evaluation. N2stands for a new level 2 visit, etc. There is a grid for Established


patients and Consults as well that are all combined into one color-coded,easy to use reference card. For simplicity, only the New Patient grid isshown.

Follow the N3 (New level 3) section outlined in the table below. This isa common coding level for orthopaedics. To be compliant, dictate a CC, 4HPI bullets, 2 Review of Systems, and one statement concerning PH (or FH,SH). The History Templates that were designed allow you to determine thesecomponents easily and make dictation simple. After examination of thepatient, two body areas (e.g., left knee and right knee) are used to generate12 bullets (thus the 2/12 notation). The PE template is used as a guide to theselection of appropriate bullets from these two areas.

Refer to the MDM section in the table below. You only need to be Compliantin 2 of the 3 sections. Typically on a New Patient with knee pain, you interpretx-rays (2 data points), determine a New Diagnosis (3 Dx points, but you onlyneed 2) and treat with a prescription NSAID (good enough for N4, but you onlyhave to take “Risk” associated with OTC Advil for N3). Most orthopaedicevaluations can easily fall into this N3 grid. Meeting the criteria for MDM isfairly straight forward.

N1 N2 N3 N4 N5

Hx CC Y Y Y Y YHPI 1 1 4 4 4ROS 1 2 10 10PH 1 1 1FH 1 1SH 1 1PE BA/bullets 1/1 1/6 2/12 4/30 4/30MDM (2 of 3)

Data 1 1 2 3 4Dx 1 1 2 3 4Risk Ace wrap Lab Test Advil Script Scope—RF Surgery1 RF

Neurological loss

The grid can be simplified further. It became so easy to obtain a completehistory with the templates that it was just as easy to dictate an N5 level Historyon every patient than try to remember even the simplified rules. In addition, theMDM section can be understood by referencing the criteria for an N4 level. Thissimplified pattern gave us a starting point from which to remember the rest ofthe rules and made understanding and retention much better. The simplified gridis seen below. The tools used to make the dictation simple are listed first.

Tools

HPI TemplateROS/PFSH TemplateDictation TemplatesP.E. TemplateDictation TemplatesX-ray TemplatesTreatment Templates


N1 N2 N3 N4 N5

CClevel 5 history on all patients using templatesHPIROSPHFHSHP. Exam BA/bullets 1/1 1/6 2/12 4/30 4/30MDM

Data 3*Dx 3 (New)Risk Script

*This has been called the orthopaedic “3 point play.” Achieve one point for ordering an x-Rayand 2 points to interpret.

Simplify the history bullets by creating a level 5 history every time usingtemplates. It became unnecessary to remember the bullet count required for thehistory for all the 5 different levels. The physical exam is simplified bydesignating how many body areas (BAs) are needed to generate the appropriatebullets for each level of exam. MDM is simplified by remembering the criteriafor an N4 visit. All other areas are then referenced to this level. Since MDM isalready done well by most orthopaedic surgeons, a little work learning thedetails can be quite helpful.

Authors Typical Routine for N3 Left Knee Pain

I would like explain the use of tools and templates for the typical patient seenfor knee pain. For the moment, assume a healthy new patient with knee pain andan appropriate “nature of presenting problem” who does not require extensivecounseling and has a completely negative ROS. In this example, as with mostorthopaedic patients, the key components of history, physical examination, andmedical decision making will determine the level of service.

The new patient will complete the History Templates (Medical Question-naire) forms in the waiting room. The medical assistant places the patient in theexam room and reviews the form for completeness. Vital signs are only takenon patients expected to be an N4 or N5 level visit (unless clinically indicated)since they are not needed to generate the 12 bullets for an N3 level visit.

The surgeon then obtains the CC and HPI from the patient (already outlinedby the patient in bullet format on the history form) and clarifies and commentson the patient’s responses on the form. The surgeon reviews the ROS, PH, FH,and SH on the form and adds comments to the form for any pertinent responses.Pertinent negative findings are noted. The form is signed and dated. Theappropriate physical exam is performed, emphasizing 2 BAs (left knee andcomparison right knee) as well as observations concerning the patient’s appear-ance, orientation, mood, and affect and gait. (which typically would not havebeen documented in the past).

The surgeon would then obtain and interpret x-Rays (assume they are nor-mal), consider a differential and then make a diagnosis, possibly treat withNSAIDs and an injection, and arrange follow-up, and create a letter to theconsulting physician.

The dictation would then be created with the templates as seen in the tablebelow. Note how the templates and tools allow more bullets into the dictation


with fewer words of dictation.The words in italics are the words generated bytemplates (macros).

What You Dictate What is Typed

CC Left knee pain CC Left knee painHPI (read from History form)“This is a 45 year old male seen at

the request of Dr. Smith withleft knee pain for 3 monthswithout injury. The pain is onthe medial side, is 6 out of 10severity, has a sharp, stabbingquality that is intermittent innature associated with swellingand not relieved withconservative treatment.”

HPI This is a 45 year old male seen at the request ofDr. Smith with left knee pain for 3 months withoutinjury. The pain is on the medial side, is 6 out of 10severity has a sharp, stabbing quality that isintermittent in nature associated with swelling and notrelieved with conservative treatment. (41 bullets)

ROS/PFSH “Template CompleteROS”

A complete Review of Systems and Past, Family, andSocial History was performed using HealthQuestionnaire of (date), no comments required.(14ROS/3 PFSH). Must sign History Form

PE “Template Intro limp left” P.E. Physical exam reveals the patient is welldeveloped, well nourished, alert and oriented times 3,with normal mood and affect who walks with a leftsided limp.(4 bullets)

“The left knee reveals tendernessover the medial joint line, fullrange of motion, negativeLachman’s test and normalquadriceps strength.” (add anyadditional tests required)“Template. Right knee”

The left knee reveals tenderness over the medial jointline, full range of motion, negative Lachman’s test andnormal quadriceps strength. (4 bullets)

The right knee reveals no tenderness, full range ofmotion, negative Lachman’s test and normalquadriceps strength.(4 bullets)

X-Rays: “Template Normal Leftknee”

X-Rays: AP, lateral and sunrise view of the kneewere obtained in the office today and reveal noperiosteal reaction, no medullary lesions, noosteopenia, well aligned joint spaces and nochondrolysis. (3 Data points)

IMP: “Left knee pain withpossible medial meniscus tear”

IMP: Left knee pain with possible medial meniscustear (3 Dx points—new Dx)

Plan: 1) Template Inject Leftknee”

Plan: 1) After discussion of options for treatmentand risks of injection, the patient agreed to proceedwith injection.Procedure: After sterile prep the left knee wasinjected with cc of lidocaine and cc ofCelestone. The patient tolerated the procedure withoutcomplications. Post injection pain and blood sugarelevation was discussed.(minor surg)

2) Voltaren 75 mg 2 po bid. GIside effects reviewed.

2) Voltaren 75 mg 2 po Bid. GI side effectsreviewed. (Prescription drug)

3) Physical therapy 2 visits forhome exercise program.

3) Physical Therapy 2 visits for Home exerciseprogram.

4) Follow up 6 weeks 4) Follow up 6 weeks“Template consult letter” Transcriptionist createsa letter and inserts the

diagnosis and plan and sends copy of office note.


Advantages from Improving Compliance

Although most physicians consider compliance a burden, there are someadvantages to both the patient and the physician that result from improveddocumentation. The quality of the medical record as an independent represen-tation of the encounter is greatly improved, even though the medical judgmentthat occurred during the encounter is not significantly altered. This improves thecommunication between health providers and can only benefit the patient. Inaddition, if a level 5 history is performed on all patients regardless of severityof condition (as recommended by the author), then improved health screeningcan occur.

The physician benefits since the work actually performed during the encoun-ter is documented allowing the physician reimbursement that is legitimate forthe level of effort. In addition, the threat of claims of fraud will diminish, whichcan only improve the moral of the physicians and the perceived integrity of thepublic.

What is the Next Step to Improve Compliance?

There are a few options available for the orthopaedic surgeon to improvecompliance in E&M dictations. These include:

1. Learn the 1997 Guidelines in their original format and personally createtemplates and tools. This is a time consuming task but provides the knowl-edge base for compliance.

2. Obtain commercially available templates and tools from various consultantswho can also provide education and training in the process of compliance.

Karen Zupko and Associates has been identified by the AAOS as a source forconsultation and has offered seminars on coding that are highly recommended.The return on investment (in both time and dollars) from a thorough under-standing of this confusing topic will be remarkable. They can be reachedthrough the AAOS.

The author has developed a compliance system that is commercially availableand was designed specifically for the orthopaedic surgeon. It incorporates manyof the tools and templates described above.

3. Purchase an Electronic Medical Record System to help documentation.Although not the subject of this article, there is an extensive learning curvefor each of the various computer systems available. If this can be overcome,there can be a dramatic improvement in compliance as well as improvedefficiency in office functions that represents the future in medical documen-tation.

REFERENCES

1. 1997 Documentation Guidelines for Evaluation and Management Services.2. AAOS Guide to CPT Coding.3. CPT 2001.


ARTHROSCOPIC SURGICAL CODING

Jack M. Bert, M.D.

At least 30% of orthopaedic surgery practices lose significant revenue everyday due to lack of a reliable claims submission coding compliance meth-

odology. Without good compliance of both the surgeon and coder, the averagepractice makes coding errors on no fewer than 30% of the claims it submits. Insome audits of orthopaedic surgical groups, the coding error rate was as high as65% in specific claim codes submitted (1). 80% of the net income of orthopaedicpractices in the U.S. is from surgery professional fees (2). Furthermore, 80% oforthopaedists do arthroscopic surgical procedures and 60% of all orthopaediccases performed are arthroscopic (3). Therefore, surgical coding error rates cantranslate into a huge loss of practice income for the orthopaedic practice. It istherefore critical to educate both the physician and the in office coder on correctcoding techniques to insure maximum reimbursement.

“Correct” Surgical Coding

“Correct” surgical coding is knowing when to use which modifiers and whatcodes to apply to each surgical procedure. It is paramount to document every-thing in the operative report and list the specific procedures performed. This willallow the coder to generate the appropriate codes for the procedures completed.It is important to note that time is not a key component relative to coding ofsurgical procedures.

The common procedural codes are termed “CPT” codes. The major or singleprocedure performed is termed the “Index Code.” If a more significant proce-dure which contains the index procedure is performed, then that code is termedthe “Comprehensive Code.” The comprehensive code would supercede theindex code and “contains” it. If the second code is listed as comprehensive to theindex code, then use the comprehensive code instead of the index code forbilling because more work is performed in the index code, it will have a higherreimbursement.

Multiple Procedures

Multiple procedures require a specific work effort or the work is not reim-bursable. If the surgery performed is part of a more extensive procedure or doneincidentally to gain access to a compartment, then that specific surgery is notreimbursable as part of a multiple procedure. For example, when doing a kneearthroscopy, removal of synovium to gain visualization or access to an area isnot reimbursable. The synovial disease should be a distinct disease entity suchas rheumatoid arthritis.

Two lesions that are close anatomically can still be distinct entities. Forexample, a medial femoral chondral defect and medial meniscal tear aredistinct pathological entities. Other distinct lesions include meniscal tears,loose bodies, torn ligaments, labral tears, chondral defects or primarysynovial disease.

Modifiers

Modifiers are used when coding to justify the appropriate billing for theservices provided. These are added by a two digit number after the procedure


coded separated by a hyphen. The more significant modifiers used for codingarthroscopic procedures will be discussed.

Modifier 22 (Unusual Procedural Services) is usually not reimbursed by thepayers but it has improved. If you decide to use it, make sure you send a detailedoperative report and a cover letter explaining the reason for the unusual servicesperformed.

Modifier 26 (Professional Component) is used for x-ray and MRI interpreta-tion. The problem is that you need to send a signed copy of radiographicinterpretation in order to be eligible for reimbursement. You might use this at aleased satellite clinic but you can’t charge for your services if a radiologist hasalready billed for the reading. This is better served with usage of E & M codes.

Modifier 47 (Anesthesia by Surgeon) is used if the surgeon administersregional anesthesia, add this modifier to both the procedure code and theanesthesia code. However, local or digital blocks do not qualify and mostinsurers including HCFA do not reimburse for this modifier!

Modifier 50 (Bilateral Procedures). Reimbursement is usually 150% of thesingle procedure; however, some coders will list each procedure separately andobtain 100% of both procedures. This has regional variations and excludingMedicare appears to be at the discretion of the payer.

Modifier 51 (Multiple Procedures) if performed at the same time, append themodifier to all appropriate procedures after the first one. Use the procedure withthe highest RVU reimbursement on the HCFA 1500 form and list it first andthen add the 51 modifier to all additional procedures. HCFA will pay 100% ofthe 1st procedure, then 50% for the 2nd through 5th procedures. Your codershould bill full charges for all procedures and let the carrier determine how itwants to reduce payment on subsequent procedures. Do not make the mistake ofreducing your charges before sending them to the carrier or they may reducethem again so you will obtain 25% reimbursement of the 2nd through 5th

charges.Modifier 54 (Surgical Care Only) is used if one surgeon performs the surgery

and another surgeon provides the pre- and postoperative care. For example, ifyou inherit a patient who has had surgery performed elsewhere, you would usethis modifier to charge for postoperative care.

Modifier 55 (Postoperative Management) is used if you perform postoperativemanagement and someone else did the surgery. Make certain that the originalsurgeon used the modifier 54 or your care will be part of the global fee and thenit is not reimbursable.

Modifier 56 (Preoperative management) is used when one surgeon performsthe preoperative care and another surgeon performs the surgical procedure in thesame global period. For example, if you admit the patient and do the history andphysical exam and your partner does the surgery. Note that any preoperativemanagement within 24 hours of surgery is in the global period.

Modifier 57 (Decision for Surgery) is in the global period covering E & Mservices for 24 hours prior to a procedure unless the E & M service during thatglobal period is the one in which the decision to perform the surgery is made.For example, if the orthopaedist is asked to see a patient with a fracturedhumerus in the emergency room and then evaluates the patient. He then decidesto operate and takes the patient directly to surgery. The E & M service shouldbe coded for which is the initial hospital care with the modifier257 appendedto the E & M service and then code for the operative procedure.

Modifier 59 (Distinct Procedural Service) is used to indicate that a procedurewas independent from other services performed at the time. For example, if a


chondroplasty is performed on a femoral condyle in the same or different kneecompartment from the meniscectomy, this modifier would be added to themeniscectomy code and should be reimbursed 150%. This modifier has beenused to unbundle procedures that have previously been bundled by the “correctcoding initiative” when these bundled procedures have actually been performedseparately.

Modifier 78 (Return to the OR during the postoperative period, related) isreserved for a complication of the original procedure such as drainage of ahematoma.

Modifier 79 (Return to OR during the postoperative period, unrelated) isreserved for returning to the OR for an unrelated procedure such as repair of ahumeral fracture after rotator cuff repair.

Modifier 80 (Assistant Surgeon) is used if the assisting M.D. remains in theOR for a majority of the procedure. The certified physician’s assistant is valuedat 13.6% of the fee paid to the surgeon. In some areas of the country, the asst.surgeon obtains 50% of the fee and the P.A. gets 25%.

Modifier 99 (Multiple Modifiers). When using multiple modifiers after a CPTcode, add299 to the basic procedure.

Coding of Knee Arthroscopic Surgical Procedures

29870: Diagnostic knee arthroscopy is almost never used. Comprehensivecodes should be used in ALL cases since they are more descriptive and arereimbursed greater than 29870.

29871:Arthroscopy, lavage for infection. This code essentially stands alonesince there are no comprehensive or concurrent codes that can be associatedwith it.

29874:Arthroscopic loose body removal. By definition a loose body must be5 mm. or greater and be removed by mechanical means, NOT flushing. Con-current codes (Add251) include, 29877: arthroscopic chondroplasty (debride-ment of articular cartilage).

29876:Arthroscopic synovectomy, major (2 or more compartments)Concurrent codes include; 29874—Arthroscopic loose body removal

29877—Arthroscopic chondroplasty29881—Arthroscopic meniscectomy

29877:Arthroscopic chondroplasty (shaving)Comprehensive code; 29879—Abrasion or drillingConcurrent codes include; 29874—Arthroscopic removal of loose body

29880—Arthroscopic med. & lat. meniscectomy29881—Arthroscopic med. or lat. meniscectomy

29879:Arthroscopic abrasion or drillingConcurrent codes include; 29874—Arthroscopic removal of loose body

29880—Arthroscopic med. & lat. meniscectomy29881—Arthroscopic med. & lat. meniscectomy

29880:Arthroscopic medial & lateral meniscectomyComprehensive codes include; 29882—Medial or lateral repair

29883—Medial & lateral repairConcurrent codes include; 29874—Arthroscopic removal of loose body

29876—Arthroscopic synovectomy, major29877—Arthroscopic chondroplasty29879—Arthroscopic abrasion or drilling

29881:Arthroscopic medial or lateral meniscectomy


Comprehensive codes include; 29880—Medial & lateral meniscectomy29883—Medial & lateral repair

Concurrent codes include; 29877—Arthroscopic chondroplasty29885:Diagnostic arthroscopy, drilling of OCD lesion

Concurrent codes include; 29874—Arthroscopy, removal loose body28877—Arthroscopy, debridement, chondroplasty

29888:Arthroscopic ACL or PCL reconstructionConcurrent codes include; 29880/29881—Arthroscopic medial &/or lateral me-

niscectomy29883/29882—Arthroscopic medial &/or lateralmeniscal repair

There are “Emerging Technology” Knee Codes which have NO RVU valueassigned as yet which are being introduced as of 1/0/02. It will be the respon-sibility of the practitioner to negotiate with the insurance carrier the value ofthese codes. These “tracking codes” include:

0012T—Arthroscopy, knee, surgical implantation of osteochondral graft(s)for treatment of articular surface defect, autografts

0013T—Allografts0014T—Meniscal transplantation, medial or lateral, knee (any method)

Coding of Shoulder Arthroscopic Surgical Procedures

Medicare has indicated that unlisted arthroscopic shoulder procedures mustbe reported using CPT code 29909 (unlisted procedure, arthroscopy, this codechanges to 29999 as of 1/1/02). When processing code 29909, enter a descriptorin item 19 of the HCFA 1500 form but donot add the comparable CPT codebecause you will be reimbursed at a lower level. Arthroscopic CPT descriptorsinclude;

23120: Arthroscopic excision of clavicle23410: Arthroscopic rotator cuff repair—acute23412: Arthroscopic rotator cuff repair—chronic23450: Arthroscopic capsulorrhaphy—anterior23465: Arthroscopic capsulorrhaphy—posterior23466: Arthroscopic capsulorrhaphy—multidirectional23455: Arthroscopic Bankart repair

Arthroscopic shoulder procedures not meeting the above descriptions and sub-mitted with an aggregate code (unlisted code) must attach the operative reportwith the claim. This policy has been in effect since 8/1/00.

One technique for coding arthroscopic shoulder procedures which do not havea designated code is to select analogous codes and send a KISS (keep it simplestupid) letter comparing the procedure to a Bankart procedure #23455. By doingthis, the coder is both establishing a basis for reimbursement and providingjustification for the fee. Highlight the differences between the codes as well asthe similarities pointing out that the arthroscopic procedure is technically moredifficult. Furthermore, it is worthwhile to point out that the insertion of fixationdevices is difficult to perform arthroscopically. Estimate that the arthroscopicSLAP repair is 10% more difficult than the Bankart procedure and then request110% of the carrier’s normal fee for the Bankart procedure. The “KISS” letterMUST be signed by the surgeon.

For arthroscopic rotator cuff repairs, put #23410 (open rotator cuff repair) inBox 19 of the HCFA 1500 form and bill 25% higher than the open code for theincrease in technical difficulty! Also, complete the “remarks section” on the


HCFA 1500 form with as much information as possible to explain the procedureeven if it is in the “KISS” letter.

In summary, when using analogous codes, use 29909 which is the unlistedprocedure code (29999 after 1/1/02) since it is an unlisted procedure. Thenreview existing codes to select the best comparative code. Establish a fee for theunlisted procedure from 10 to 30% greater than the amount for the openprocedure. Finally, prepare a letter explaining the procedure and justifying thefee. If the procedure is experimental, send a peer review article attesting to theefficacy of the procedure. If the unlisted procedure code or analogous codebilling is refused payment, then ask the carrier to provide the practice withalternative codes and they should submit these in writing.

The NEW arthroscopy shoulder codes effective 1/1/02 are as follows;29805: Arthroscopy, shoulder, diagnostic29806: Arthroscopy, shoulder, surgical capsulorrhaphy (arthroscopic Ban-

kart)29807: Arthroscopy, shoulder, surgical, repair of SLAP lesion23824: Arthroscopy, shoulder, surgical; distal claviculectomy including distal

articular surface (Mumford procedure)29990–29902: Arthroscopy of the MCP joint (3 codes)29999: Unlisted procedure, arthroscopy

The following codes represent common arthroscopic shoulder procedures.29819:Arthroscopic removal loose body

Comprehensive codes include; 29820—limited synovectomy29822—limited debridement

Concurrent codes include; 29826—shoulder arthroscopy with subacromial de-compression w/without CA release23120—Partial claviculectomy23450/23466—Capsulorrhaphy, ant./multi. instab.

29822/29823:Arthroscopy, limited/extensive debridementConcurrent codes include; 23420—Rotator cuff repair

23450/23466—Capsulorrhaphy, anterior/multi di-rectional instability29826—Subacromial decompression23120—Partial claviculectomy

23000:Removal of calcium deposits, openConcurrent codes include; 23400—Biceps tenodesis

29909:Arthroscopic stapling of glenoid labrum (unlisted). Compare to con-current codes for highest RVU values. Note, after 1/1/02 this can be coded29807.

Remember, when coding arthroscopic shoulder procedures, do not code for adiagnostic arthroscopy, use a comprehensive code. Use modifier 59 (distinctprocedural service) for the second procedure if done through different portals.Use modifier 51 (multiple procedures) if done with an unrelated open procedure.Note that if an open procedure supplants a closed procedure, you can’t code foran arthroscopic procedure unless the procedure is in a different compartment.

Coding of Elbow Arthroscopic Surgical Procedures

29830:Arthroscopy, diagnosticComprehensive codes include; 29834—Removal of loose bodies

29835/29836—Partial/comp. synovectomy29837/29838—Limited/ext. debridement


Concurrent codes include; 24006—Arthrotomy of elbow24130—Radial head excision24350—Lateral epicondylar release

29834:Arthroscopy, removal of loose bodyComprehensive codes include; 29835/29836—Partial synovectomy

29837/29838—Limited/ext. debridementConcurrent codes include; 24006—Arthrotomy of the elbow

24130—Radial head excision24350—Lateral epicondylar release

29835:Arthroscopy, partial synovectomyComprehensive codes include; 29836—Complete synovectomy

29837/29838—Ltd./extensive debridementConcurrent codes include; 24006—Elbow arthrotomy

24130—Radial head excision24350—Lateral epicondylar release29834—Removal loose body, arthrotomy

29837:Arthroscopy, limited debridementComprehensive codes include; 29836—Complete synovectomy

29838—Extensive debridementConcurrent codes include; 24130—Radial head excision

29834—Arthroscopy, removal loose body

Coding of Wrist Arthroscopic Surgical Procedures

29840:Arthroscopy, diagnosticComprehensive codes include; 29844—Partial synovectomy

29845—Complete synovectomy29846—Debridement29847—Fracture or instability

29844:Arthroscopy, partial synovectomyComprehensive codes include; 29845—Complete synovectomy

29846—Debridement TFCC repair & debride-ment29847—Arthroscopy plus ORIF or repair of fx.or instability

29845:Arthroscopy, complete synovectomyComprehensive codes include; 29847—Arthroscopy, plus ORIF or repair of fx.

or instabilityConcurrent codes include; 25999—Joint manipulation

29846—Joint debridement29848—Periarticular nerve release

29846:Arthroscopy, debridement, repair of TFCCConcurrent codes include; 25240—Limited ulnar head resection

29847—Arthroscopy for fx. or instability29848—Periarticular nerve release

29847:Arthroscopy, ORIF for fx or instabilityConcurrent codes include; 25620—External fixator application

29848—Periarticular nerve release29848:Arthroscopy, release transverse carpal ligament

Comprehensive codes include; 64721—Open release of carpal tunnelConcurrent codes include; 29847—Any arthroscopic wrist procedure

64719—Any ulnar nerve procedure


64727—Median nerve neurolysis using magnifica-tion

Coding of Ankle Arthroscopic Surgical Procedures

29891:Arthroscopy with repair of OCD lesionComprehensive codes include; 29892—Repair of tibial/talar dome fxConcurrent codes include: 29894—Arthroscopy with loose body removal

29895—Arthroscopy with partial synovectomy29897—Arthroscopy with limited debridement29898—Arthroscopy with extensive debridement

29892:Arthroscopy, repair of tibial/talar dome fx.Concurrent codes include: 29894—Arthroscopy with loose body removal

29895—Arthroscopy with partial synovectomy29897—Arthroscopy with limited debridement29898—Arthroscopy with extensive debridement

29894:Arthroscopy with removal loose bodyConcurrent codes include: 29891—Arthroscopy, removal defect, drilling

29892—Arthroscopy, repair tibial/talar dome fx.29895—Arthroscopy with partial synovectomy29897—Arthroscopy with limited debridement29898—Arthroscopy with extensive debridement

29895:Arthroscopy, synovectomy, partialComprehensive codes include: 29897—Limited debridement

29898—Extensive debridementConcurrent codes include: 29891—Arthroscopy, removal defect, drilling

29892—Arthroscopy, repair tibial/talar dome fx.29894—Arthroscopy, removal loose body

29897:Arthroscopy, limited debridementComprehensive codes include; 29898—Extensive debridementConcurrent codes include: 29891—Arthroscopy, removal defect, drilling

29892—Arthroscopy, repair tibial/talar dome fx.29894—Arthroscopy, removal loose body

29898:Arthroscopy, extensive debridementConcurrent codes include: 29891—Arthroscopy, removal defect, drilling

29892—Arthroscopy, repair tibial/talar dome fx.29895—Arthroscopy, partial synovectomy29894—Arthroscopy, removal loose body

Conclusions

Remember to documenteverythingthat you do in the operative report and listALL the procedures that were performed. Insist on thorough operative reports!

Getting maximum reimbursement for an unlisted procedure requires detaileddocumentation. If there is a legitimate reason for two codes and modifier 59 ormodifier 51 applies to the situation, operative notes MUST support the inde-pendence of the procedures.

List the code with the highest RVU factorfirst whether it’s the index vs. thecomprehensive code.

If you feel that you have done more than the code allows, send the operativereport along with a letter explaining why the reimbursement should be increasedand add modifier222 to the code (unusual procedure)

Lastly, BE CREATIVE, there is MORE THAN ONE WAY TO CODE!


Example Coding Questions and Answers

1. KNEE PROCEDURE CODING QUESTION:Arthroscopic medial menis-cectomy, debridement and partial synovectomy.ANSWER:29881: Arthroscopic medial meniscectomy (Can’t code for partialsynovectomy since it is necessary to gain access to visualize the torn meniscusand is considered “incidental” to the torn meniscus pathology)

2. KNEE PROCEDURE CODING QUESTION:Arthroscopic medial menis-cectomy with ACL repair using hamstring tendon autograftANSWER:29888: Arthroscopically assisted ACL repair

29881-51: Arthroscopic medial OR lateral meniscectomy. Use mod-ifier 251 because this is multiple procedure. Use 29888 first since itis the higher reimbursed of the two procedures20902: Autograft harvesting in the same setting from another area ofthe body, e.g., hamstrings. If you are using an ALLOGRAFT, youcan’t charge for harvesting since the surgeon did not obtain the graft.If the surgeon harvests, then the graft can be coded separately.

3. KNEE PROCEDURE CODING QUESTION:Arthroscopic medial menis-cectomy & chondroplasty of the medial or lateral femoral condyleANSWER:29881 (Index code): Arthroscopy of knee, meniscectomy (medial or

lateral includes meniscal shaving)29877: “Chondroplasty” is a significant procedure even though it isin a single compartment & therefore should be considered a concur-rent code. (Most commonly reimbursed ONLY if performed in adifferent compartment)

4. SHOULDER PROCEDURE CODING QUESTION:Arthroscopic sub-acromial decompression and mini-incision rotator cuff repairANSWER:29826: Decompression of subacromial space with anterior acromio-

plasty w/without CA ligament release.23412: Repair of chronic rotator cuff tear

5. SHOULDER PROCEDURE CODING QUESTION:Arthroscopic repair ofavulsed anterior glenoid labrumANSWER:29909: Arthroscopic repair of avulsed anterior glenoid labrum

Has no code until 1/01/02. 29909 is the “unlisted procedure” code(29999 after 1/01/02).Always submit a letter for SLAP repairs describing the procedure assimilar to Bankart repair (23455)

6. SHOULDER PROCEDURE CODING QUESTION:Arthroscopic debride-ment & capsular shrinkageANSWER:29822/29823: Shoulder debridement, limited./extensive

29909 (29999 after 1/0/02): Unlisted arthroscopic procedure plus a59 modifier (distinct procedural service) to indicate that it wasdistinct & independent from the debridement. Some carriers maywant 51 (multiple procedures) attached to 29909 (29999 after 1/01/02).

7. ELBOW PROCEDURE CODING QUESTION:Arthroscopy of elbowwith loose body removal and partial synovectomyANSWER:29834: Arthroscopy of elbow with loose body removal

29837: Arthroscopy with debridement, limited. Use loose bodyremoval as the index code and limited debridement as the concurrentcode which should give a greater reimbursement

8. ANKLE PROCEDURE CODING QUESTION:Ankle arthroscopy for a


talar dome fx. is performed then aborted due to inability of the surgeon to repairthe fx. He proceeds to an arthrotomy and open repair with internal fixationANSWER:29892–53: Arthroscopic repair of OCD lesion, talar dome or tibial

plafond fracture includes scope. Use the 53 modifier for “discontin-ued procedure”28445–59: Open treatment of talar fx. with or without ORIF. Use the59 modifier for “unusual procedural services.” Send both the oper-ative note and a clarifying letter


Coding and reimbursement in arthroscopic surgery

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