December 1998 Bulletin

It pays to learn diagnosis coding

Failure to master skill can result in late or denied reimbursement

By Margaret Maley

Diagnosis coding is the nemesis of many surgeons and coders. The ICD-9-CM book is cumbersome and difficult to master even if you are a seasoned user. As a result, many reimbursement teams spend little time refining this coding skill. Unfortunately, payers delay or deny reimbursement based on the diagnosis codes. For example: charges for debridement of open fractures (CPT codes 11010-11012) may be denied unless the diagnosis code describes an open fracture. Similarly, using a level 5 Evaluation and Management (E/M) code to evaluate a simple uncomplicated problem could raise a red flag to payers. The diagnosis code should support the level of service rendered or the procedure performed by the orthopaedic surgeon.

In an effort to reduce delays and denials, you should be aware of the most costly diagnosis coding errors we find when delivering consultative services to orthopaedic practices.

Use of nonspecific codes

Billing for orthopaedic services requires facility with a large number of diagnosis codes. In an effort to conserve space on encounter forms or surgical charge tickets, we often see nonspecific codes listed. This is a mistake. You must code to the highest known level of specificity. Do not code "fracture of radius and ulna lower end, closed" (813.4) when you are treating a "Colles' fracture" (813.41). The four-digit code 813.4 requires a fifth digit and using it without the additional number could lead to payment delay. Your documentation should reflect the verbiage of the ICD-9-CM book.

Code comorbidities

Third-party payers keep statistical "report cards" on providers. They know, by diagnosis, your average length of stay, complication rate and overall cost of treatment. If you're known in the community as a surgeon who can treat the most complicated disaster cases, your "profile" may also be a disaster unless you document the diagnosis and co-morbid conditions with care. We are not suggesting that you code every diagnosis for which the patient has ever received treatment. But, you should code those conditions that could effect outcome. For orthopaedics, these would generally include: diabetes, rheumatoid and autoimmune diseases, osteoporosis and neuropathies and dementia. Even smoking (tobacco dependence 305.1) is an important co-morbid circumstance if you are fixing a fracture or attempting to achieve spinal fusion. Smoking would not be listed as a diagnosis if you are seeing a patient for a knee sprain or other condition where there is no causal relationship.

Link diagnosis/procedure

Whenever possible, it is best to link a single diagnosis to a single procedure. For example, if you perform an ACL reconstruction and a medial meniscus repair in the same operative session, the arthroscopic ACL reconstruction (29888) should be attached to the diagnosis for rupture of the ACL (844.2), and the medial meniscus repair (29882) attached to the diagnosis for torn medial meniscus (836.2).

Failure to code late effects

Late effect is the residual problem of an illness or injury that occurs after the acute phase. If you have a late effect you must also code what created the late effect. Example: A patient treated for a malunion of a tibia fracture should have the following diagnoses listed:

733.81 Malunion of fracture

905.4 Late effect of fracture of lower extremities

Always code the residual problem as the primary diagnosis and the cause as the secondary diagnosis. Codes for the causes of late effects are selected from categories 905 through 909 in the ICD-9-CM book volume.

Code all patient complaints

You are seeing a 67-year-old patient in good general health with a chief complaint of bilateral knee pain. During the history, the patient mentions he is also having some shoulder pain that he would like evaluated. You examine the upper extremity, discuss it with the patient, but neglect to document the evaluation in your note or list the diagnosis. Big mistake. Code 715.16 for osteoarthritis of knees and 726.10 for tendonitis of the rotator cuff. Document the history, exam and decision-making involved in arriving at these diagnoses.

Orthopedic surgeons must stop "giving away" care and start documenting the extent of the work they are already doing consistently in the E/M process. In this era of shrinking reimbursement, we can little afford to refund money to payers because we do not have documentation.

Margaret Maley is a consultant with KarenZupko and Associates. She developed and is an instructor for the national coding and reimbursement series sponsored by the American Academy of Orthopaedic Surgeons.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

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