Orthopedic Coding Alert

Critical ways you can combat carrier challenges

CPT coding is not an exact science, and the AMA hasn't yet released a code for every procedure that orthopedic surgeons perform. Therefore, orthopedic coders resort to unlisted-procedure codes almost every week. But unlisted-procedure codes don't have to mean automatic denials or write-offs. Read on for tips on how to hone your reporting strategies and boost your bottom line.

Choose Unlisted Over Close Coding

When CPT doesn't offer you a specific code for your surgeon's service, you must report an unlisted-procedure code such as those listed in the Clip N Save article later in this issue.
 
Coders may be tempted to avoid reporting unlisted- procedure codes because doing so too often can lead to a denied claim or a long delay in reimbursement. Because of this, some coders erroneously report codes that are close to the procedure instead of the appropriate section's unlisted-procedure code. That's not a good habit to acquire, for a number of reasons.

The primary reason this is inappropriate is that you-ll face accusations of incorrect coding. -Selecting a code that is -close- is not compliant coding,- says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. 

Use Category III Codes When You Can

In addition, if you don't report unlisted-procedure  codes, you may eliminate your chances of ever seeing a permanent CPT code assigned to the service.

One way that the AMA tracks the need for new codes is through the unlisted procedures that are reported. At some point, the association may create a Category III code for further tracking.
 
Category III codes exist to help the AMA determine whether there is a need to create a CPT code for the service, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

If Medicare never receives submissions of the Category III codes, the services will never get Category I CPT codes assigned to them.

Modifiers Don't Take the Place of Unlisted

 If your practice avoids reporting unlisted-procedure codes by simply modifying existing codes with modifiers 22 (Unusual procedural services) and 52 (Reduced services), you may be shooting yourself in the foot because of the way CMS assigns relative value units (RVUs) to codes.

-When it's time to create a CPT code for a procedure, if offices have been reporting the procedure using unlisted-procedure codes, the specialty will receive new RVUs for the new code. If they-ve been using an existing code with a 22 or 52 modifier attached, the specialty will have to steal RVUs from established codes to fund the new code,- Cobuzzi says.

Enlist Outside Help

Medical technologies often evolve faster than the CPT manual, and drug and equipment manufacturers have a vested interest in making sure that carriers pay physicians for using the latest innovations, even if CPT codes don't exist to describe them.

If your surgeon uses equipment and techniques for which CPT does not include a code, you may be able to enlist the manufacturer's help collecting appropriate reimbursement.

Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies. And they are sometimes instrumental in gaining approval for new CPT codes to describe previously unlisted procedures.

But use caution when you apply the manufacturers- suggestions.

Remember: You are responsible for the accuracy of your claims, and you should never misrepresent a claim to gain payment. Stick to unlisted-procedure codes when no other code describes the procedure you performed, and always provide ample documentation to justify the claim's necessity.

If the manufacturer suggests a code that makes you feel uneasy, double-check the advice with your surgeons and your carriers.

Prepare to Address Roadblocks

Once your unlisted-procedure claim reaches the carrier, the next challenge is finding carrier representatives who educate themselves about new (and proven) technology or procedure techniques and therefore understand your claim.

How should you meet these challenges? Education and documentation are your best bets.

Impress With Your Letter

Cover the bases with your cover letter. An information-packed cover letter with your claim plays an important role in reimbursement. Follow these three tips for an impressive cover letter:

1. Write a brief paragraph explaining why you are using the unlisted-procedure code.

2. Include a paragraph explaining the procedure that the surgeon performed, and why it is medically necessary for this patient. Also, summarize other procedures the patient has undergone without successful relief.

3. Include a brief paragraph explaining the basis for the fee you submitted for the unlisted procedure.

Common denominators between existing codes and the procedure you performed include similar work, practice expense and malpractice risk to a -valid- CPT code. Basing your fee on a similar procedure is helpful but not mandatory.