Orthopedic Coding Alert

When it comes to ICD-9 coding, you can't believe everything you hear You assigned the correct CPT codes and appended all of the required modifiers, but the carrier still denied your claim. You may be a victim of some common diagnosis coding myths that made you assign incorrect ICD-9 codes to your claim.
 
The following orthopedic coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement. Myth 1: Once you precertify, you can't add diagnoses. You precertified a surgery based on one diagnosis, but after the orthopedist started the surgery he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right?
 
Not so fast. You can either precertify a code range or submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, coding and auditing department supervisor at Orthopedic Specialists of the Carolinas in Winston-Salem, N.C.
 
Suppose the orthopedist diagnoses a torn anterior cruciate ligament (ACL, 844.2) and acquires the insurer's preapproval to perform an ACL repair (29888). Once the orthopedist begins surgery, he also discovers a torn lateral meniscus (836.1) that the radiologist was unable to read on the MRI. The orthopedist then repairs the meniscus (29882) and ACL during the same session and reports both codes with the torn ACL and torn meniscus diagnoses.  
 
Because the insurer preauthorized only the surgery based on the torn ACL diagnosis, should the practice report both procedures?
 
Yes, but you can avoid this challenge if you precertify a code range rather than just one code, Fulton says. "Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says. Precertify a Code Range Instead of One Code "When we call the insurer to precertify a knee scope, we give the code range of 29870-29889 for certification purposes," Fulton says. "We tell the insurance company's pre-cert department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."
Insurers rarely ask surgeons to precertify just one CPT and diagnosis code.
 
In rare cases, however, the insurer might ask you to simply precertify the intended procedure based on the confirmed diagnosis. "In this case, we would of course give them the 29888 for the ACL repair, but we would reiterate that it is completely possible that more procedures will be performed and reported."
 
If, after the surgery, the insurance company balks at paying for the meniscectomy, the surgeon should write an appeal letter citing the date his practice requested preapproval, the fact that the practice attempted to precertify a code range, and that he diagnosed a torn meniscus using [...]