Orthopedic Coding Alert

You-ve charted your E/M code usage against averages--now take the next step
 
In the July Orthopedic Coding Alert, we showed you how you can compare your practice's E/M code usage against other orthopedic surgeons-. But most coding consultants recommend that you shouldn't stop with just your E/M code utilization.
If you want to really dig deep, says Randall Karpf, president of East Billing in East Hartford, Conn., compare your surgeon's surgical bench-marking statistics against other surgeons nationally, other orthopedists within your practice, and against his own code usage from the prior year.

If you aren't sure whether your physician's elbow surgery coding is on the right track, check out our guest column on page 13 to make sure you-re assigning the right codes. Once you know that your code assignment is right on the money, you might be interested in determining whether you bill more high-level surgeries than other orthopedic surgeons.

We-ve listed benchmarking data for selected elbow surgery codes in the 'Clip and Save' article to follow. But before you jump in full speed ahead, don't forget the following benchmarking advice. We asked Jim Gdula, MBA, business manager at Central Texas Spine Institute and president of the BONES Society, to answer the most frequently asked questions about surgical benchmarking:

Don't Worry If Your Codes Are Higher Than Others-

Question 1: If our surgical practice reviews the benchmarking data and sees that our billing pattern reveals higher-level surgical codes than the majority of coders report, should we be worried, or are there other factors involved?

Answer: -I believe that there are several other factors that the practice should look at prior to jumping to conclusions that they are overcoding,- Gdula says. 
 
-Perhaps the practice is highly specialized and thus attracts the -tougher- cases such as failed prior surgeries or cases that less specialized surgeons are not comfortable with.-

An example of this might be a case referred from a general orthopedist to an orthopedic surgeon who is fellowship-trained in upper-extremity orthopedic problems, he says.

Another reason, Gdula says, is that the practice may be known in its geographic area as a -preferred- provider because they-re affiliated with a respected medical center.

Reminder: -Do not assume that just because other practices code -lower- than your practice that they are right and you are wrong,- Gdula says.

-Review CPT descriptions to make certain that the coding reflects the actual work performed,- he says. If you are not comfortable and well-versed in coding, consider contracting with a coding expert to audit a sample of your coding versus the narrative in your operative reports.

Benchmark Against Yourself
 
Question 2: I have heard consultants recommend that surgeons should benchmark their code usage against their own code usage. What does this mean and why do specialists recommend it?
 
Answer: -I would highly recommend that physicians benchmark against themselves over time, as well as against other physicians in the same practice,- Gdula says.

Why should you do this? -Perhaps over time the surgeon becomes more comfortable taking on more complex cases, and thus his or her coding pattern would escalate legitimately,- Gdula says.

On the other hand, he says, the surgeon may simply be coding more aggressively without realizing it or without realizing that certain CPT definitions may have been modified with a more recent version of CPT, thus changing the coding recommendations for the procedures that surgeons performed.

Another reason: Perhaps a colleague, because of training or reputation, is getting all of the -difficult- cases that come into the practice, Gdula says, which would justify his billing higher-level surgical codes.

-On the other hand,- he says, -maybe a colleague is coding more aggressively, justified or otherwise. Differences within a practice should be reviewed by the practice administration so that revenue can be maximized but trouble can be avoided.-