Orthopedic Coding Alert

Carefully read the physician's notes to extract ICD-9 codes

In the perfect coding world, our physicians would support the coders- efforts by providing CPT codes for all services rendered, properly document these services, and then link their procedures to supporting ICD-9 codes. But let's have a reality check -- it rarely works like that. 

Hopefully your physicians realize the importance of coding and have taken a more active role in this function. The amount of participation is going to vary greatly, so we as coders need to be able to fill in the gaps.

The gaps may be simply checking for bundling edits and solid linkage between your procedures and diagnoses but, unfortunately, may often mean combing through lengthy office documentation and complicated procedure notes to assign all codes and diagnoses on your own. 

The provider has hired you for your coding expertise and trusts that you will do as much background work as  possible so that when you do have to seek clarification, the physician will be able to determine, due to the documentation, why you had to ask what you did.
 
This interaction allows the coder to learn and make notes so you are prepared the next time the same situation presents itself. In addition, the providers will learn where their documentation is deficient so they can then supply us with all information needed to make the process a smooth one -- from rendering the service, to having the claim go out the door quickly so they can be paid for what they are doing. 

Check the Notes for Clues

Let's examine some examples of situations in which  the coder must fill in the gap when the provider has not written a diagnosis on the patient's superbill. 

Example 1: The physician's superbill shows a level-three consult with a knee orthosis (L1810). It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code.

First step: We refer to the dictation, which reads: -The patient is a 13-year-old female being evaluated as a consultation at the request of Dr. Jones for left knee pain. Left knee pain started on 12-9-06 when she did splits during cheerleading.- The physician completes the remaining history, ROS, PFSH and exam.

Moving down through the chart note, we see that the patient brought an MRI with her that demonstrated a contusion of the medial femoral condyle.

Under a separate heading, the doctor has given his assessment, which states: Left medial femoral condyle contusion and MCL sprain.

Next step: We look up -Contusion- in Vol. 2 of the ICD-9 book, and the most specific body area listed is -knee,- which is 924.11 (Contusion of lower limb and of other and unspecified sites; knee). We turn to Vol. 1 and read the information under the -Contusion- heading to read for exclusions and see that none apply in this case. We search under 924 to see if by chance we had codes for specific areas of the knee joint, which there are not. We know then to assign 924.11.

Look for additional diagnoses: The second diagnosis listed is an MCL sprain, and following the same process of checking Vol. 2 first under -Sprain, strain,- we check -knee,- which gives several codes beginning with the non-specific code of 844.9 (Sprains and strains of knee and leg; unspecified site of knee and leg). Further down, the manual lists a code for a sprain of the medial collateral ligament, but it is listed as an -old- sprain. 

We know from the history that this is not correct because the patient's sprain is not old, but no code appears here for an acute sprain of the MCL. You would also find upon checking Vol. 1 under 844.9 that more specific sites are listed under the 844 heading and there is one listed for the MCL. If you continue to read the codes listed under 844, you will find that -medial collateral ligament of knee- has its own code of 844.1 (Sprains and strains of knee and leg; medial collateral ligament of knee). 

Diagnoses found: The correct ICD-9 assignment for this claim would therefore be 924.11 followed by 844.1. 

Rule Out Ambiguity

You may also encounter blank superbills along with documentation that mentions tests to -rule out- certain conditions. But because you can never report a diagnosis listed as -rule out,- you-re up a creek if you can't pin down an accurate diagnosis. Our next example illustrates this point.

Example: The physician's superbill includes the procedures circled and the diagnosis written as -rule out fracture.- We can tell by the x-rays ordered and obtained that the body area in question is the left forearm. But the phrase -rule out fracture- gives us no more information than a superbill without any diagnosis at all.

First step: Reading through the dictation, we find that this is an 11-year-old girl who was riding piggyback when she fell on her left arm. She had immediate onset of pain, and she has continued to complain of pain. A detailed exam is documented, and x-rays are ordered and interpreted as -AP and lateral of the left forearm are negative for acute bony abnormality.-

The doctor states in the documentation, -the mother was told that occult fractures can occur in children, and you cannot be 100 percent sure that no fracture is present, but the exam and x-ray seem to indicate that there is no fracture.-

Next step: The physician offers his impression as -contusion of the forearm,- so you then know not to use a fracture diagnosis for this encounter. You should report 923.10 (Contusion of upper limb; forearm) as your diagnosis for this visit. 

Never Submit a Diagnosis Based on a Guess

Use the internet, medical dictionaries, etc., for resources, but never guess. When in doubt, ask your provider. Your ICD-9 selection is going on record for this patient and may affect his ability to get medical insurance in the future.

An example of guessing incorrectly that comes to mind resulted in reporting that a patient had gonococcal arthritis (098.50), which is an infection of joint that occurs with gonorrhea. The coder reported this code because the provider had written -gonarthrosis- (which means -knee arthrosis-) on the superbill. Without more specific information, it should have been reported as 716.96 (Arthropathy, unspecified; lower leg).

The best thing you can do is to read through and familiarize yourself with the coding guidelines printed in the front of your ICD-9 book. There is a wealth of information there, and should you be questioned on your code assignment you should be able to cite from the guidelines how you arrived at your selection. These are the official guidelines that have been approved by AHA, AHIMA, CMS and NCHS, and adherence to these guidelines is required under HIPAA. 

Leslie Follebout, CPC, is the coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md.