Coding Tips for the Orthopedic Office. Webinar Subscription Access Expires December 31.

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1 Coding Tips for the Orthopedic Office Questions Answers Webinar Subscription Access Expires December 31. How long can I access the on demand version? You will find that in the same instructions box you utilized to access this presentation. Subscription access expires December 31, individual purchases will not expire for at least two years. If you are the purchaser, you can find your information through following these steps: 1. Go to & login 2. Go to Purchases/Items 3. Click on Webinars tab 4. Click on Details next to the webinar 5. Find the instructions box in the middle of the page. Click on the link to the item you need (Presentation, MP3 file, Certificate, Quiz) Where can I ask questions after the webinar? The online member forums, where over 100,000 AAPC members have access to help each other with all types of questions. *Forum Posting Instructions* 1.Login to your online account 2.In the middle of the page you will see discussion forums 3.Click on view all top right hand side 4.Select general discussion under medical coding unless you see a topic that suits you more 5.On the top left side of the forum box, you will see a blue button, new thread click on that 6.Type your question and submit 7.Check back in that location for answers as you please

2 Hi Lynn, this is Helen Parise your old student for coding, can you please contact me via thanks Do you bill modifier 51 with 29826? with CPT you do but experts state you don't? PA state fee schedule for WC billing is always a fun chore... Do you need seperate xray report or separte heading Imaging in the patients chart for medicare patients? On page 145 in the 2012 CPT it states tp append modifier 51 with Another thing we've seen with WC is the 25% bite that MCOs take from our payment. Ouch! When do you have insurance eligibility and verification done. AT the time of visit or prior to the pt coming in? For 10 global days procedure, if the next follow up appt was on the 11th post op day, will this f/u visit be coded as regular office visit versus 99024? Thank you Helen. Check the CPT errata on the AMA website that parenthetical notation has been deleted about appending modifier 51 on code Because it is an add on code, a 51 would not be necessary Many states are a challenge. The State of IL recently cut the fee schedule by 30% If you are billing the X-ray then yes the X-ray report should be in the medical chart. Check the CPT errata on the AMA website that parenthetical notation has been deleted about appending modifier 51 on code That doesn't seem fair, but could be part of the guidelines based on your state rulings. It is probably best practice to have it done prior to the visit, so that you office flow is not interrupted. Also, determining coverage in the past will allow you to discuss with the patients any responsibilities they may have before they are seen. The 11th day would be a billable E/M.

3 As auditing a patient then you are saying the ortho doctor needs two different documentations, one for the progress note and a writen radiiology report by the ortho doctor? Please refer to the Medicare Claims Processing Manual, Chapter 13, 20.1 in reference to the professional component requirements for radiology and other diagnostic procedures. MY interpretation is that while it does not specifically say that the report has to be separate, it does require a complete report, which is defined as what a specialist in the field would prepare, and that it cannot be part of the E/M service. My clients do have separate reports, that are sometimes pulled out of the dictation by transcription, so that it is not interpreted as part of the E/M service. My Ortho dr sees a new patient for a radius fx and he charges for a office visit and a fracture code. Is there a certain modifier that needs to go on the office visit to get it paid? Regarding E codes and using dx categories , if no injury is mentioned in the documentation, would you not report an E code or would you choose to use a non speicified E code. Do you feel they are mandatory when you use a primary dx from the series? When the patient is a new patient and there is documentation to support the E/M level and the fracture treatment is performed on the patient, if the global days for that fracture is 90 days, modifier 57 is usually the modifier to append to the E/M level. If you do not have the information to choose an E code, they are not required. There should be an understanding though, that your claim may be delayed because the insurance carrier may request accident information. With the new Ill Medicaid reimburse rules for podiatric physician on a non diabetic patient can the podiatrist order X ray & RX or does that need to be done by PCP for patient to have coverage? You will have to check the fee schedule available on the IL Medicaid website specific to Podiatrists. They list the codes that will be payable as well as when the will be reimbursed.

4 If the ortho MD is billing global for xray done in the office, at the time of the visit, does the ortho MD need a separte written xray report in the chart or will report in progress note undert he imaging heading survise? Please refer to the Medicare Claims Processing Manual, Chapter 13, 20.1 in reference to the professional component requirements for radiology and other diagnostic procedures. MY interpretation is that while it does not specifically say that the report has to be separate, it does require a complete report, which is defined as what a specialist in the field would prepare, and that it cannot be part of the E/M service. My clients do have separate reports, that are sometimes pulled out of the dictation by transcription, so that it is not interpreted as part of the E/M service. We give out theraputty in the office visit with cpt code and it is being denied by commerical insurance companys. Is there something we are forgetting to add so we quit getting these denies For outpatient hospital setting, can institutional/facility fee be billed for visit? If the pt is currently in a global for CTS Lt side and the next visit the pt is seen for CTS Rt side. So the doc would like me to add a 24 modifier to the visit. Is this appropriate, some insurances deny becuase it's the same Dx code is orthotic management and training, which is working with the patient that has been given an orthotic, such as a brace. Theraputty does not have a specific CPT or HCPCS code, but our clients use either or A9300 because it is a supply. It is my understanding that global periods are not recognized for facilities. Because there is no global period, the facility should be able to report an E/M service for reimbursement. You may end up appealing the claim, but modifier 24 is appropriate. Although the diagnosis is the same, it is considered a separate visit because it is the other hand.

5 When the patient comes in to the office for a complication to the surgery, for example Wound Infection, and patient is referred to wound care. Can we not bill the office visit with 24 modifier? What is your opinion on the physician being called to the ER to see a patient. They perform a consultation and then perform a procedure. Can we bill for the consult/e&m separately with modifier 25 if documented completely? It would not be a major procedure. Something like a closed reduction under anesthesia. It may depend on the payor. The carrier, if there is not a return to the OR or other procedure room, may consider it part of the post-op care. According to CMS new guidelines, it would not be separately billable, but other payors may accept. Patient comes into the office a week post-op from a knee arthroscopy with an effusion which requires aspiration. Is that billable or considered part of the surgical global package? we share Immediate care physicians with an ortho group in same office, Immedicate care MD see patient and then send to Ortho MD same day, how can I bill Immedicate care MD so both get paid for fracture or injury care, is there a modifier that can be used, also x-rays ordered, do I need a modifier This would be included in the global package. A return to the operating room would be when a related procedure in the global period is performed If the Immediate care physician does the evaluation then they would code the E/M visit and sends the patient to the ortho group for the fracture care then the Immediate care physician reports the E/M service and the ortho group bills the fracture care code. For X-rays it depends who is interpreting the X-rays. If the Ortho group is interpreting the X-rays then the Ortho group bills the X-ray code and appends modifier 26. Modifier 26 is only appended if the ortho group does not own the equipment, and only interpets the X-ray.

6 If the provider documented a procedure within the exam key component, for example examined knee and injected with kenalog. In the MDM key component knee, pain and rx. With History also documented, can this be coded with E&M-25 and injection CPt code? I think you just said that IL Medicaid only has a 30 day global period. Is that for Orthopaedic only or all specialties? I just want to make sure I heard you correctly! What injection code would you use for the CMC joint. Our Ortho Dr's say it is the distal part of the wrist. Is this considered the the or 20600? Not sure my question went through...what is your opinion on the physician being called to the ER to see a patient. They perform a consultaiton and then perform a procedure. Can we bill for the consult/e&m separately with modifier 25 if documented completely? It would not be a major procedure. Something like a closed reduction under anesthesia. Thank you. According to CMS new guidelines, it would not be separately billable, but other payors may accept. That would be for all specialties, not just orthopedics I would use for the wrist. According to CMS new guidelines, it would not be separately billable, but other payors may accept.

7 what if Immediate care MD starts treatment for the fracture, cast, wrap,splint, how would that be billed if ortho see same day? modifers use so both providers can get paid same date for same treatment of injury? we are an Immedicate care facility You should be reporting a visit and the casting, splinting, etc. Fracture care should be reported only if you are going to follow the patient. It also could be reported as fracture treatment with the use of modifiers 54, 55, or 56. Your facility would bill for your part ot the treatment, and the provider following up the patient would bill the treatment with the appropriate modifier. Example: Patient has had injections in a knee and /or shoulder and comes back for a follow up visit in 3-4 months, what ICD9 code is used. if the patient says he is pain free doing great? what code would you use for piriformis muscle injection? with fluoro?? Patient comes to the office and is a new patient with Medicare insurance coverage. The physicians decides the patient would benefit from a cortisone injection. Based on CCI edits for 2012 can we bill the initial visit with a 25 modifier along with and the cortisone? If the patient is coming back for only follow-up with no further treatment then use follow-up code form category V67. If the patient is coming back and needs further treatment then you need an after care code. Go to the ICD-9- CM guidelines in the beginning of your ICD-9-CM manual. Guideline I.C.18.d.7 and I.C.18.d should be reported should be reported for the fluoro According to CMS new guidelines, it would not be separately billable, but other payors may accept.

8 Is there a code for a failed fusion? Example...ankle? I am assuming you are looking for an ICD-9 code. You should refer to complications. The three digit category of 996 could be a possibility depending on the method of fusion relative to bone grafting and/or internal fixation In the CPT book, procedure indicates aspiration and/or injection of ganglion cyst(s), however in parentheses below it indicates to report multiple ganglion cysts use appending modifier "59". Would you please clarify. Thank you. for their 2nd visit on the do you add a 58 modifier? Do you have problems with self insured reimbursing for cast materials. we always have issues with this So are you saying with the repeat casting visits we can charge the application of the cast also along with the casting supplies? Thank You Q codes not recognized for PA Workers Comp When the surgeon uses fluroscopy in surgery to make sure a pin is in the correct place (example...pinning a wrist) is that fluro included in the main surgery CPT code? Modifier 59 would be appended to the second to indicate that it was a separate ganglion cyst and not multiple aspirations fo the same ganglion cyst. Yes, modifier 58 is used on subsequent casts in the global period I do not see any specific reason why self insured would reimburse differently. You may however, check any contracts you may have to see if this is addressed. Many may use that supplies are included. That is correct, the application and supplies are billable. I have heard from some providers around the country that some carriers do not pay for the supplies and deny it as inclusive You could then report the A codes A4580 and A4590 CCI edits and most other insurance carriers include fluoro guidance in surgery. It is going to be on a carrier basis. Some of our clients bill it, some do not.

9 can we charge and e&m and an initial fx care charge for the 1st fist with a 57 modifier on the e&m? Are we allowed to bill for casting, slings, etc. during the post op period? Thank you. According to CMS new guidelines, it would not be separately billable, but other payors may accept. The AAOS believes it is acceptable Yes, they should be separately reported based on the CPT guidelines related to casts that states the initial casting or splinting would be included in the procedure, but reporting subsequent casting and splinting is acceptable patient with fracture has casts applied in er and sent to ortho specialist for follow-up. xrays show significant elbow fracutures so ortho doc replaces cast and refers patient to another specialists that specializes in Elbow fractures. Should the first ortho doc bill an E/M and cast OR can she bill the closed treatment codes? Unless everyone is reporting the treatment codes with the appropriate modifiers 54, 55, 56, the provider that will follow the patient should be the one to report the treatment. Is there a website I can go to in order to see the workers comp fee schedule? The workers comp fee schedule would be relative to your state. Going to the states official website may offer a link to the workers compensation site. If your state has a workers comp fee schedule, it should be listed there. If cast is removed by a different dr than the one that applied the cast, and the dr that removed the cast is in the same practice as the dr that applied the cast, can the removal of the cast be charged to ? CPT refers to providers in a group practice of the same specialty should be seen as one physician, with that being said, if one dr in your group applied the cast, another dr of the same group cannot report the removal

10 Thank you. We do bill for them in the office during the post op period with the appropriate modifier, however I just went to a seminar and they advised us not to bill for them. I am not sure what question this response is referring to. In the Karen Zupko course, we were told that new to 2012 the initial E&M could be billed along with the non operative fracture code. Is this correct As stated in other answers, the AAOS feels it is appropriate. Please see the reference below related to Medicare guidelines AS A REFERENCE FOR E/M SERVICES FROM CMS. IT IS IN THE NCCI GENERAL CODING PROCEDURES REVISED 1/1/2012. PAGES CHAPTER I GENERAL CORRECT CODING POLICIES FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES