Orthopedic Coding Alert

Signs and symptoms may sometimes be the best -- or only -- choice
Although the correct CPT code may indicate the work your orthopedist did, if you fail to attach the correct diagnosis code, you could be heading for denials.

 Follow these expert recommendations to ensure you-re properly coding patients- signs, symptoms and diagnoses. 1. Watch for 4th- and 5th-Digit Requirements Correct coding requires that you be as specific as possible. That means your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.

You should always use the fourth or fifth digit when ICD-9 requires it -- or anytime you have that information. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated.

Pitfall: Don't assume what isn't in the medical record.

Example: If you are coding for a closed proximal humerus fracture, you cannot simply report 812.0, because four digits alone don't make for a complete diagnosis. Instead, you must specify a fifth digit of 0 (for an upper end fracture, unspecified part), 1 (for a surgical neck fracture), 2 (for an anatomical neck fracture), 3 (for a greater tuberosity fracture) or 9 (for an other upper humeral fracture, such as of the head, upper epiphysis or lesser tuberosity).

Tip: If the medical record does not allow you to code to the required specificity level, check with the reporting physician for guidance. -Physicians are notorious for this when it comes to osteoarthritis,- says Jill M. Young, CPC-EDS, of Young Medical Consulting LLC in East Lansing, Mich. -Without the notation of generalized or localized, you end up with a nonspecific code regardless of whether the physician told you where it was on the body.- 2. Call on Signs and Symptoms When your physician provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If the physician cannot document a definitive diagnosis, however, report the patient's signs and symptoms to support medical necessity for services the physician provides.

Avoid -rule outs-: ICD-9 coding guidelines state that you should not report -rule out- diagnoses in the outpatient setting. You-ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, your physician will still get paid for his services, even if he cannot establish a definitive diagnosis.

-Look to see if the physician has given the patient a definitive diagnosis,- says Denae M. Merrill, CPC, physician coder for Covenant HIM in Saginaw, Mich. --Rule out,- -suspected,- -probable- or -questionable- are not codeable. If there is no definitive diagnosis given, look for [...]