Orthopedic Coding Alert

Many orthopedic practices see arthritic patients at various stages of their treatment. Depending on the severity of the arthritis and the services offered by the orthopedic practice, an arthritic patient may be followed on a long-term basis by the same physician or may be treated by many different providers in the practice, both physicians and nonphysician practitioners. Repetitive, long-term care such as this often results in missed opportunities to code for and obtain fair reimbursement.
 
Following the Patient

 
The following case study illustrates how much care the arthritic patient may need and where coders should be alert to coding opportunities. Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., takes readers through a long-term plan of care for an osteoarthritic patient, in this case a 62-year-old male with symptomatic osteoarthritis of the right knee, 715.16 (osteoarthrosis, localized, primary; lower leg). 
 
Evaluations Are Made

 
"Typically a patient with osteoarthritis might start with his primary care physician, who then refers him to a rheumatologist," Stout says. The rheumatologist has been treating the patient with conservative measures such as NSAIDS (nonsteroidal anti-inflammatory drugs). Due to increasing symptoms, now poorly controlled by the use of NSAIDS, the rheumatologist requests an orthopedic consultation. 
 
The orthopedic surgeon (OS) evaluates the patient, takes and reviews x-rays in his office and determines that due to a deformity of the knee caused by long-term osteoarthritis, 736.42 (genu varum [acquired]), the patient is a candidate for a total knee arthroplasty.
 
Other treatment options are reviewed, including a series of Hyalgan injections, because the patient is reluctant to have surgery. The OS offers an injection of Celestone for short-term symptomatic relief. The patient accepts and an injection is given, but he defers any further decision until he has had time to consider each treatment option. "This is fairly typical," Stout says. "An orthopedic surgeon will list one or more alternatives to surgery, which patients often see as a 'last resort.' "
 
This initial meeting with the orthopedist is coded as follows:
 

99204x-25 -- office consultation for a new or established patient ... The modifer -25 is appended to indicate that the injection was a separate procedure from the E/M (consultation) code.
 

7356X -- radiologic examination, knee (depending on the number of views taken)
 

20610 -- arthrocentesis, aspiration and/or injection; major joint or bursa
 

J0702 x 2 -- injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg (two units of Celestone).
 
 
Terry Fletcher, BS, CPC, CCS-P, an independent coding and reimbursement specialist in Dana Point, Calif., reminds coders it is essential that their physicians choose the most specific diagnosis code. "Physicians tend to record an unspecified arthritis code such as 715.00 (osteoarthrosis, generalized, site unspecified) instead of identifying the location and the type of arthritis. This is likely to get kicked back by carriers, particularly in cases of ongoing treatment,'' she says.
 
Hyalgan Injections Scheduled

 
Six weeks later, the patient returns for follow-up and, after more discussion, agrees to Hyalgan injections in an attempt to forestall surgery. The physician administers one injection and schedules the patient to come back twice for a total of three injections.
 
"It is important for coders and physicians to remember that after the initial visit, subsequent visits with the patient are no longer consultations," Stout says. The patient is now an established patient, and the orthopedist has assumed coordination of his care and treatment. Therefore, the follow-up visit is coded as an established patient E/M office visit, 99211-99215. "This is a common pitfall of coding when patients are sent from another physician,"  Stout says. "But in virtually every case, once they've been seen the first time and then return, particularly for the same problem, they are no longer consultations." 
 
At the visit where the patient decided to proceed with Hyalgan, the physician can charge for both the E/M service and the injection if the documentation requirements for the E/M service are met, appending modifier -25  to the E/M code. The injection is charged as follows:
 

20610
 

J7315 -- sodium hyaluronate, 20 mg, for intra-articular injection (aka Hyalgan).
 
 
The above codes would be reported without an E/M code on the two occasions when the patient returns for injections. Because the injections were scheduled procedures, the orthopedist cannot bill for an E/M visit in addition to the injection codes. ICD-9 codes for the injections would be the same as for the initial visit: 715.16 and 736.42.
 
Knee Surgery Performed

 
The patient has positive results from the series of Hyalgan injections for one year, but then experiences renewed symptoms. During an E/M visit with the orthopedist (99211-99215), he decides to schedule his total knee arthoplasty.
 
Two weeks later, the orthopedist admits the patient and performs a routine total knee replacement (TKR), which is 27447 (arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing [total knee replacement]). On postoperative Day 2, the patient complains of severe low back pain. The orthopedist evaluates the patient and orders and reviews x-rays, which are unremarkable. The pain resolves spontaneously two days later. The patient is discharged on postoperative Day 5.
 
Code 27447 is reported for the TKR, linked to diagnostic codes 715.16 and 736.42. Code 99232-24 (subsequent hospital care, per day, for the evaluation and management of a patient ...) is reported for the evaluation of the patient's back pain and linked with ICD-9 code 724.2 (lumbago). The -24 modifier is appended to the inpatient E/M code to indicate an unrelated evaluation and management service by the same physician during a postoperative period.
 
Follow-Up to Surgery

 
The patient sees the orthopedic surgeon in his office six weeks after surgery. The physician examines the patient and takes and reviews x-rays of the knee.
 
Code 99024 (postoperative follow-up visit, included in global service) is reported for record-keeping purposes even though it is not a billable charge. The x-rays of the knee are billable and reported using applicable codes from the 73560-73565 range, depending on the number of views taken. The corresponding ICD-9 codes are the same, 715.16 and 736.42
 
The patient then sees the orthopedic surgeon in his office 11 weeks after surgery. The physician examines the patient and determines that he has developed a flexion contracture of the knee. X-rays of the knee are taken and reviewed, and the physician schedules a manipulation of the knee joint under anesthesia for the next day. 
 
This follow-up visit is coded (but not billed) as 99024. The x-rays (7356x) are a billable charge. The codes are 718.46 (contracture of joint, lower leg) and V43.65 (organ or tissue replaced by other means, knee) to indicate the prosthetic knee.
 
In the operating room, the physician performs a manipulation of the knee joint to release the contracture. This procedure is coded as 27570-78 (manipulation of knee joint under general anesthesia [includes application of traction or other fixation device]; return to the operating room for a related procedure during the postoperative period). Using modifier -78 is the only way to get many commercial payers to reimburse for the complication from surgery and the only way that Medicare will pay for any related care in the global surgical period. The codes reported are the same, 718.46 and V43.65
 
Following the patient's recovery from the manipulation, the orthopedic surgeon initiates and supervises an aggressive physical therapy program. The physical therapist is an on-site employee of the orthopedic practice. The initial appointment with the physical therapist is for evaluation and to create a plan of care for the patient. This first visit is coded 97001(physical therapy evaluation).
 
Codes for physical therapy include 718.46, V43.65, and the original code for osteoarthritis, 715.16. Because the deformity to the knee has been corrected with surgery, 736.42 is no longer applied.
 
Subsequent therapy sessions are coded based on what was done at the visit, i.e., 97110 (therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility); 97022 (application of a modality to one or more areas; whirlpool); 97124(therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion]).
 
Fletcher cautions coders to be sure to vary the physical therapy codes reported (based on what was done), rather than report 97110 for each session.  "97110 is sort of a 'catchall' physical therapy code," she says, "and too generic for long-term therapy." She also recommends that coders not schedule or bill E/M services on the same day as physical therapy because one of the two codes will be rejected.
 
Fletcher say physicians should schedule a physical therapy re-evaluation (97002) approximately every 15 therapy sessions. "This will show the carrier whether or not progress is being made, and justify the continuation of physical therapy," she says.