Orthopedic coding can get complicated fast, as you well know, and the ways to go wrong and risk your hard-earned reimbursement are many. That’s why we asked Chris Boucher, editor-in-chief of TCI’s Orthopedic Coding Alert, and orthopedic coding expert, Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., Milltown, NJ how they would handle three reporting scenarios our readers found challenging.
If you struggle with open fractures, spontaneous dislocations, and decompression fasciotomies, read on to boost your coding know-how and put an end to time surrendered to orthopedic coding uncertainty.
Our orthopedic surgeon treated a patient with an open transverse radial shaft fracture. Before performing the repair, he cleaned the skin around the injury, then debrided the foreign material and necrotic tissue. The provider also removed injured tissue in and around the site of the fracture. He then irrigated the tissue layers before performing open treatment of the fracture with internal fixation. How should I report this encounter?
Solution: You should report a code for the fracture treatment as well as a code for the debridement. On the claim, report 25515 (Open treatment of radial shaft fracture, includes internal fixation, when performed) for the fracture treatment. Be sure to append S52.32- (Transverse fracture of shaft of radius) to 25515 to prove medical necessity for the procedure.
Then, report 11010 (Debridement including removal of foreign material at the site of an open fracture and/ or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues) for the debridement. Choose the most descriptive diagnosis code you can based on the notes; from your description, the best choice is S61.50- (Unspecified open wound of wrist).
Note: Patients suffering from fractures will often need wound cleaning or debridement for their injuries, especially if the injuries occurred in some sort of accident. From your description of the provider’s actions, 11010 is the best debridement code for your encounter.
There are some other debridement codes you might consider in these situations, as well. If the situation warrants, you might choose 11011 (… skin, subcutaneous tissue, muscle fascia, and muscle) or 11012 (… skin, subcutaneous tissue, muscle fascia, muscle, and bone) instead of 11010.
In every fracture/ debridement claim, choose the debridement code that most closely describes the encounter.
What is a spontaneous hip dislocation, and how do you code surgeries for this injury?
Solution: Spontaneous dislocations are, by their nature, typically congenital or pathological in patients. When your surgeon documents treatment of a closed hip dislocation, you’ll choose from the following CPT® codes, depending on the specifics of the encounter:
Notes indicate that our provider performed a decompression fasciotomy on a patient’s lower left leg after a level-two evaluation and management (E/M) service. How should I report this encounter?
Solution: Your code choice will depend on the type of fasciotomy and patient status. We’ll tackle each individually.
Fasciotomy: For the patient’s decompression fasciotomy, choose one of the following codes depending on encounter specifics:
No matter which of the above codes you choose, you might need to indicate laterality by appending modifier LT (Left side), if you payer requires it.
E/M service: Your question indicates that your provider performed a level-two E/M service for the patient, but you didn’t specify whether the patient is new or established.
If it is a new patient, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making … ).
For an established patient, you’ll want to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making … ).
Modifier alert: Regardless of which E/M code you choose, be sure to append modifier 57 (Decision for surgery) to the E/M if the surgery is a decompression fasciotomy you’re coding with 27600, 27601, or 27602. You’ll also use modifier 57 if the procedure turns out to be a decompression fasciotomy with debridement, as these codes all have a 90-day global period.
If, however, the procedure turns out to be an I&D rather than a decompression fasciotomy, you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code, as these procedures have global periods of 10 days.
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The Coders’ Specialty Guide 2019: Orthopedics (Volume 1 & II) includes all CPT® and HCPCS codes relevant to orthopedics, simple descriptions that explain each code, expert advice for assigning codes, Medicare reimbursement details, diagnosis codes crosswalk, applicable modifiers, CCI edits, global days, code index, hundreds of anatomical illustrations, and more.