Transcript Evaluation and Management Services

Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation

Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Global package
› Pre-op H&P
› Consent
› Local anesthesia
› Surgery
› Simple wound irrigation
› Intra-op x-rays
› Suture removal
› Post-op follow-up (0, 10, 90 days)

Current Procedural Terminology (CPT)
› Code breakdown
 10% pre-op assessment
 69% surgery
 21% post-op follow-up care

Relative Value Unit (RVU)
› Total
› Work
› Facility vs. non-facility

How they generate a new code

Elbow fracture, surgery with ulnar nerve
exposure

Codes
1. Elbow ORIF alone
2. Wound irrigation with elbow ORIF
3. Wound irrigation with elbow ORIF and ulnar
neuroplasty

Elbow fracture, surgery with ulnar nerve
exposure

Codes
1. Elbow ORIF alone
2. Wound irrigation with elbow ORIF
3. Wound irrigation with elbow ORIF and ulnar
neuroplasty

Open elbow fracture with ring/small finger
numbness, surgery with ulnar nerve exposure

Codes
1. Elbow ORIF alone
2. Wound irrigation with elbow ORIF
3. Wound irrigation with elbow ORIF and ulnar
neuroplasty

Open elbow fracture with ring/small finger
numbness, surgery with ulnar nerve exposure

Codes
1. Elbow ORIF alone
2. Wound irrigation with elbow ORIF
3. Wound irrigation with elbow ORIF and ulnar
neuroplasty

Correct Coding Initiative (CCI) Edits
› Bundled services
 Prep and drape
 Local anesthesia by surgeon
 Surgery (open, closed, percutaneous)
 Drains and pumps at same surgical site
 Cultures
 Access through damaged tissue; repair
 Intra-op complications and management

Modifiers
› Procedure altered in circumstance
› Procedural definition unchanged
› Two-digit attached to CPT code
Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Sections
› 10000 Skin and nails
› 20000 Orthopaedic
› 30000 Vascular
› 60000 Neurosurgery
› 90000 Medicine (includes wound care)

Orthopaedic section
› Spine
› Shoulder
› Humerus and Elbow
› Forearm and Wrist
› Hand and Fingers
› Pelvis and Hip
› Femur and Knee
› Leg and Ankle
› Foot and Toes

Categorical
› Incision
› Excision
› Introduction or Removal
› Repair, Revision, Reconstruction
› Fracture and Dislocation
› Arthrodesis
› Amputation
› Other
Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Symbols
Ø Modifier -51 exempt
+ Add-on code
64831 Suture of digital nerve
+ 64832 each additional nerve
+ 69990 use of operative microscope
▲Revised code
● New code
* Service includes surgical procedure only
* 20550 Injections; tendon sheath
Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Patient had morbid obesity, and femur nailing
took twice as long

Patient had morbid obesity, and femur nailing
took twice as long

Femur IMN -22
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Patient taken to OR for femur IMN, but because
BP dropped upon induction, anesthesia canceled
the case

Patient taken to OR for femur IMN, but because
BP dropped upon induction, anesthesia canceled
the case

Femur IMN -53
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Open elbow fracture with ulnar nerve injury,
undergoing ORIF and I&D

Open elbow fracture with ulnar nerve injury,
undergoing ORIF and I&D
ORIF
 I&D -51
 Ulnar neuroplasty -51-59
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
Day 1
› ORIF of distal radius

Day 14
› Repeat ORIF because of collapse
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Day 1
› ORIF of distal radius

Day 14
› Repeat ORIF because of collapse
Day 1: Radius ORIF
 Day 2: Radius ORIF -78
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Day 1
› ORIF of distal metaphyseal radius

Day 14
› Repeat ORIF because poor fixation of unrecognized
intra-articular split

Day 1
› ORIF of distal metaphyseal radius

Day 14
› Repeat ORIF because poor fixation of unrecognized
intra-articular split
Day 1: Radius ORIF
 Day 2: Radius intra-artic ORIF -58


Day 1
› I&D of forearm wound, but still needing second
debridement

Day 5
› Repeat I&D of forearm wound
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Day 1
› I&D of forearm wound, but still needing second
debridement

Day 5
› Repeat I&D of forearm wound
Day 1: I&D, and DICTATE PLAN
 Day 2: I&D -58


-22: Unusual procedural services
› Scarring, bleeding, obesity, etc.
› 25% fee increase
› Must quantify extent of complexity

Case 1
› Code set
719.43 / 99244-57
813.20 / 25574
813.20 / 25565-51-59
Wrist pain / outpt consult, with decision
for surgery
Open tx R radius/ulna shaft fxs
Closed manipulation of L radius/ulna shaft
fxs
 -51: Multiple procedure
 50% discount
 -59: Distinct procedural service on the same day
 Separate site

Case 2
› 25 y/o patient falls from motorcycle
› R open distal radius displaced intra-artic fx
› Manipulation performed in ED for preliminary stabilization
› Taken to OR that evening
 I&D of open fx
 ORIF

Case 2
› Code set
884.10 / 99244-57
813.52 / 25605
813.52 / 25608-59
813.52 / 11012-51-59
Complex open wound / consult, decision
for surgery
Closed tx radius with manip in ED
Open tx radius in OR
I&D of skin to bone assc with open fx
 -51: Multiple procedure
 50% discount
 -59: Distinct procedural service on the same day
 Separate session

Case 3
› 25 y/o patient falls from motorcycle
› R distal radius displaced intra-artic fx
› Manipulation performed in ED for preliminary stabilization
› 5 days later, to OR
 ORIF

Case 3
› Code set
719.43 / 99244-57
813.42 / 25605
813.42 / 25608-58
Wrist pain / outpt consult, with decision
for surgery
Closed tx radius with manip in ED, with
plan for surgery
Open tx radius in OR, 5 days later
 -58: Staged or related procedure
 Planned prospectively
 Subsequent procedure more extensive

Case 4
› 62 y/o diabetic female, had R carpal tunnel surgery last
month
› Presents with new L LF/RF triggering
› Patient seen in clinic during post-op period
› Injections of LF/RF performed in clinic

Case 4
› Code set
354.0 / 99214-24-25
727.03 / 20550-79-F2
727.03 / 20550-79-F3
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Outpt established pt; new problem, minor
procedure
Injection LF tendon sheath
Injection RF tendon sheath
-24: Unrelated E/M service during post-op
-25: Significant E/M on same day of surgery
-79: Unrelated procedure in the post-op period
-F2: L LF
-F3: L RF

Case 5
› 28 y/o female, MVA, multiple trauma
› Initial eval with Grade IIIA R humerus fx
› Taken to OR for urgent I&D and plating
› Further workup 2 days later revealed nondisplaced sacral
zone 1 fx; closed treatment

Case 5
› Code set
884.1 / 99245-57
812.31 / 24515
812.31 / 11012-51
808.43 / 27193-79
Complex open inj / outpt consult, decision
for surgery
Open tx of humerus fx
I&D of skin to bone for open fx
Closed tx of pelvic fx without
manipulation
 -51: Multiple procedure
 -79 modifier: Unrelated procedure during post-op
 No fee reduction
 Global period for humerus and pelvis separate

Case 6
› If sacral fx and humerus treated on same day:
› Code set
99245-57
24515
11012-51
27193-51
Outpt consult, decision for surgery
Open tx of humerus fx
I&D of skin to bone for open fx
Closed tx of pelvic fx without
manipulation
 -51: Multiple procedure
 50% fee reduction
Terminology
 Code Organization
 Special Codes
 Modifiers
 Case Examples
 Tips for Op Report Dictation


Pre- and post-op diagnosis
› Use ICD-9 terminology

Procedure
› Use CPT language
› Each procedure with corresponding diagnosis

Indications for surgery
› Pt age
› Reason for surgery
› Previous related surgery

Findings
› Include things such as
 Length of wound, size of skin graft
 Extensiveness of surgery (for modifier -22)

Details
› One-to-one correlation with listed procedures
› Separate into paragraphs

Plan
› Facilitates post-op care
› Allows future use of -58 modifier
Global service concept
 Code organization

› Body part
› Category
Diagnosis :: Procedure
 Documentation to justify EVERY code

› Paragraph breakdown

Code every surgery, immediately