Wiki Ortho Number and Complexity

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mhink693

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Does anyone have examples of Number and Complexity for Ortho issues? I have such a hard time differentiating between complicated vs uncomplicated. Or a patient coming in for trigger finger or just hip pain with an uncertain diagnosis. It's so hard to level out sometimes so if anybody has an tools or info on ways to figure these out I would greatly appreciate it!
 
It would be up to the physician to level these. If they are not doing so, it is their failure. The documentation is their responsibility, not yours. What this means is that there may be some serious need for education - the threat of underpayment should hopefully motivate them to make their documentation more explicit.

The entire point of the 2020 E&M revisions was to take the code level determinations away from check boxes and rubrics and focus them on MDM. The physician is responsible for level setting, as a diagnosis itself can range widely in complexity and diagnostic work involved.

Example: I saw a patient today with a clear (to me) trigger finger. She had been suffering for two months, limited in activity, in significant pain. She had seen a Prinary Care NP who misdiagnosed her. Then saw her Primary Care MD who diagnosed her with "arthritis" and sent her to me. Sorting through the misdiagnosis, misconceptions and related misdirection was substantial MDM work. The eventual diagnosis of trigger finger is not really germane to the complexity of the work (especially for the primary care folks who wouldn't know a trigger finger if it bit them in the behind apparently). For this encounter, you could easily characterize this as a New condition with Uncertain Prognosis. Honestly doesn't matter because column 2 and 3 were both Low complexity so it's a Level 3 visit plus injection with a -25 modifier. The point is that the ICD-10 code should have little bearing on the ultimate code leveling.

Any condition that is likely to last more than a year and which is not at its ultimate treatment goal is "chronic with exacerbation or progression" and Moderate MDM for Column 1. It is -very- easy for your physicians to document that a patient is not at his or her treatment goal.

Any condition which, left untreated or undertreated, could lead to significant morbidity or functional compromise, is an "acute, complicated injury." Also easy to document.

You can and should ask the physician to document these things clearly if they want the extent of their MDM to be appreciated. It should fall on your shoulders.
 
It might help to look at it the other way and level the visit by the other two MDM elements first if it is preventing you from coding the level using MDM and not time. "Just" hip pain isn't always "just" that. If you are a new coder to orthopedics it can be difficult, especially if the documentation isn't great or clear. When you say uncomplicated vs. complicated those terms normally apply to acute illness/injury. Those (in general) should be easier to spot. Usually, it is the chronic illness/problem that is more difficult. However, most times, if the patient is coming in to an orthopedic surgeon/specialist, it's not because they are stable unless it's a basic follow-up like if they are post-op but out of the global and they say, yup looks good, take care & only come back if needed.

It's not a great idea to use an "example" list or plug diagnoses into a spreadsheet and say this one or that one is always low/moderate/high, etc. It is not that simple. You have to go by the documentation of the individual encounter. Look at the visit as a whole. Ask yourself, what's wrong, how bad is it, what are they doing about it and how soon did they tell the pt to come back in? Seems crazy, but that can sometimes help a coder.

Are you coding for a big group, multiple subspecialties, or only one or two service lines? Have a couple examples (redacted) of what you are seeing? For example, there's a difference between a 75 y/o pt coming in to the total joint line for hip pain with known OA and has had multiple visits over time with the same MD versus the new, young pt seeing the hip preservation or limb salvage/oncology provider.

Link to another thread with some discussion: https://www.aapc.com/discuss/thread...PIJxipHANmjsaa7doM9e11DiIv0qf7_TWMd5IXMdcVCTn

Totally agree with Dr. Raizman, the provider is leaving money on the table if every office visit comes through as a 3 because the notes are poor. Also you could seek help from a senior coder or a supervisor if you don't have direct access to talk with your provider. Depending on your work environment. Physician champions and coding advocates can help too if you have access to the providers. Peer review/audit of a sample of notes can help if the provider is resistant to coder feedback.

Other links from a quick search (check dates and these are just examples): https://namas.co/acute-uncomplicated-vs-complicated-illness-or-injury/
From ACEP for the ED, but has good info as a reference: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
 
amyjph said:
It might help to look at it the other way and level the visit by the other two MDM elements first if it is preventing you from coding the level using MDM and not time. "Just" hip pain isn't always "just" that. If you are a new coder to orthopedics it can be difficult, especially if the documentation isn't great or clear. When you say uncomplicated vs. complicated those terms normally apply to acute illness/injury. Those (in general) should be easier to spot. Usually, it is the chronic illness/problem that is more difficult. However, most times, if the patient is coming in to an orthopedic surgeon/specialist, it's not because they are stable unless it's a basic follow-up like if they are post-op but out of the global and they say, yup looks good, take care & only come back if needed.

It's not a great idea to use an "example" list or plug diagnoses into a spreadsheet and say this one or that one is always low/moderate/high, etc. It is not that simple. You have to go by the documentation of the individual encounter. Look at the visit as a whole. Ask yourself, what's wrong, how bad is it, what are they doing about it and how soon did they tell the pt to come back in? Seems crazy, but that can sometimes help a coder.

Are you coding for a big group, multiple subspecialties, or only one or two service lines? Have a couple examples (redacted) of what you are seeing? For example, there's a difference between a 75 y/o pt coming in to the total joint line for hip pain with known OA and has had multiple visits over time with the same MD versus the new, young pt seeing the hip preservation or limb salvage/oncology provider.

Link to another thread with some discussion: https://www.aapc.com/discuss/thread...PIJxipHANmjsaa7doM9e11DiIv0qf7_TWMd5IXMdcVCTn

Totally agree with Dr. Raizman, the provider is leaving money on the table if every office visit comes through as a 3 because the notes are poor. Also you could seek help from a senior coder or a supervisor if you don't have direct access to talk with your provider. Depending on your work environment. Physician champions and coding advocates can help too if you have access to the providers. Peer review/audit of a sample of notes can help if the provider is resistant to coder feedback.

Other links from a quick search (check dates and these are just examples): https://namas.co/acute-uncomplicated-vs-complicated-illness-or-injury/
From ACEP for the ED, but has good info as a reference: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
Click to expand...

Thank you for the help. We have a fresh doctor that hasn't had a lot of E/M training so we are just trying to gather as many tools to help him start off. Here is a shorten version with HPI and assessment and plan. There was no imaging/lab ordered or reviewed. What would be your thoughts on the level for this?
Chief Complaint:
New Presentation Left Middle finger Pain
Is this a Workman's Compensations injury? No
Who Referred the Patient? PCP
What is your hand dominance? right handed
Date of symptom onset: 6 months
How did your symptoms occur? a gradual and insidious onset
What best describes your finger pain? locking and popping, she states it is hard to describe the pain
What is associated with your finger pain? finger weakness, limited ROM, stiffness, and swelling
Describe the timing of your pain? constant, worse in the morning
What aggravates or alleviates your pain? worse with finger movement
How severe is the pain? 5/10 currently
What are you currently using to treat the finger pain? Tylenol, Ibuprofen, steroid injection unsure when but over 2 years ago has helped until 6 months ago.
What procedures have you had to treat the finger pain? no procedures
Have you gone to PT/OT in the last 6 months for this specific body part? No
What diagnostic testing have you had for this problem? No imaging studies
How has this problem limited you? functional limitations
Who have you seen for this problem? primary care provider, and unsure who gave her the injection in the past.
Patient came to the clinic for today's visit and ambulated independently
Are you currently on any of the following medications for weight loss and/or diabetes? No
Patient has DM.


NO IMAGING OR LABS COMPLETED

Patient's exam today is consistent with trigger finger of left long digit. It is consistent with a grade III triggering and is passively correctable. She has tried conservative treatments including medications/NSAIDS and steroid injection in the past with good relief but her symptoms are recurring. We discussed she can consider surgical intervention which would consist of trigger finger release. Patient is agreeable and would like to proceed with surgery as discussed today.

PHYSICIAN DID GO OVER RISK OF SURGERY
 
99204/99214
Mod/None/Mod
Chronic exacerbated, no data, major surgery with no (patient specific) identified risks.
Some others may call it a 3.

Would be best if they comment on/mention something about the DM in the surgery discussion. Tell more of the patient specific story/thought process in words.
 
amyjph said:
99204/99214
Mod/None/Mod
Chronic exacerbated, no data, major surgery with no (patient specific) identified risks.
Some others may call it a 3.

Would be best if they comment on/mention something about the DM in the surgery discussion. Tell more of the patient specific story/thought process in words.
Click to expand...
I wholeheartedly agree. This is exactly how this should be coded, and for the correct reasons.

Your doc, if he or she is a Hand Surgeon, should come to the coding course offered at the ASSH Annual Meeting run by KZA in two weeks. There are also ample coding resources on Hand-P through ASSH. If he or she is general ortho, the AAOS also hosts many KZA-taught coding courses. The resources are out there.

Important thing to remind your surgeon - they are ultimately responsible for their coding, just as they are completely responsible for their documentation - if it wasn't documented, it didn't happen. Doesn't matter if there are coders and scrubbers behind the scenes, or if they use scribes or AI to complete their notes. They need to be educated, and they need to understand the nuances and put their best foot forward if they want to be paid appropriately for what they do. It's that simple.

There are not a lot of MD's who get deep into coding - I realize that I'm a bit of an anomaly in that. But optimizing E&M is sooo easy to teach, even to dumb orthopaedic surgeons like me. The more work you can do as a coder to educate your docs clearly, the less work there will be for you on the back end!
 
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