Coding tips for Fracture Surgeons 2016

J. Scott Broderick, MD

Director of Orthopedic Trauma

Spartanburg Regional Hospital

Disclosures

• AO Speakers Bureau

• OTA PM Committee Chair

• SEFC Secretary/Treasurer

• Reviewer JOT

• I have no conflicts associated with this presentation

Goals

• List the basic tenets of quality coding

• Explain the rationale behind wRVU utilization

• Be able to better navigate ICD-10

• Gain a few pearls in coding for fracture care

Coding

Some Things Never Change

Theory of Business

1. Reality

Reality is defined by the marketplace and goes wherever it wishes.

2. Focus

Focus is achieved when the organization aligns itself with reality.

3. Organizational Competencies

Once an organization is aware of the changes required, it must identify and develop the skills and competencies required to prosper over the long term

How can you increase revenue?

• Types of services

• Payor mix

• Contractual agreements

• Effectiveness of billing & reimbursement

– CODING

The Correct Theory of Business

“Broderick style”

• Surgeons are paid for operating

• Those who pay us use codes to describe what we do

• Surgical coding is the most important “business skill”

you can develop

• Coding is rule-based and manageable

Coding

• Assumption

– Back office clerical function

– Low physician involvement

• Reality

– Critical core competency for all of healthcare

– Physician must be knowledgeable, informed, and

actively involved

Simplicity is the ultimate sophistication

“It takes a lot of hard work to make something

simple, to truly understand the underlying

challenges and complexities, and come up with

elegant solutions.”

Simplicity

“If you need slides, it shows

you do not know what you

are talking about.”

Slide 9

Choices

Resource Based Relative Value Scale

• Developed at Harvard SPH

• 1992 Medicare National provider payment schedule

• Each CPT is assigned a relative value

– Provider work (time & intensity)

– Practice expense

– Malpractice cost

• Geographic practice cost index (GPCI)

– Economic variation in the US

• Conversion factor

Total RVU (wRVU) examples

• TKA

• THA

• ACL Reconstruction

• Meniscal Repair

• CTR

• Clavicle

• IT nail

• Tibial nail

• Bimalleolar

• Pilon (tib & fib)

• 39.11 (20.72)

• 39.12 (20.72)

• 28.42 (14.30)

• 18.38 (8.62)

• 12.23 (4.97)

• 20.69 (9.69)

• 35.49 (18.18)

• 28.77 (14.45)

• 22.21 (10.62)

• 37.29 (18.43)

A typical day in the life of an Orthopedist

• Trauma doc

– Slogs through a pilon , bimall ankle and IT hip fx

– ~7-8 hrs

• ~ 95 total RVUs

• ~ 47 wRVUs

• Joint doc

– 8 TKA/THA’s

– Flip rooms • Because he/she is special

– ~8-9 hrs (or less)

• ~313 total RVUs

• ~166 wRVUs

Contract discussions

• Not total RVUs

– Usually wRVUs

• How are final RVU totals formulated

– CPT codes that are conflicted

– Concurrent codes are reimbursed at 50%

– Based on truly reimbursable codes

International Classification of Diseases

• US National Center for Health Statistics

– 1978 “Clinical Modification”

– Updated and revised annually

– Soon to be ICD-10-CM

• Used by all third party payors in US

• Four to seven digit code used to report illness, injury, complaints,symptoms

– = diagnosis

– No code for “rule out”, “probable”, or “status post”

• World Health Organization

ICD-10

THEORY

• Increased specificity of

clinical information

• More accurate

reimbursement

• Improved quality of care

• Better disease

management

REALITY

• Enormous disruptive

change to the health care

system

• Dramatic effect on

revenue and operations

• Significant administrative

burden

• Benefits < cost ?

Interesting Y code Tidbits

• Y62-69

– Misadventures to

patients during

surgical or medical

care

• Y92.4 _ _

– Type of road for

accident

• Y90._

– Blood ETOH level

• Y92._ _

– Place of occurrence

– No “conservatory”

– Mobile home

swimming pool or

garage

• Y92.89

– Slaughter house

Systematic Approach

Courtesy of KZA

Coding Aid

Coding Aid

Coding Aid

Coding Aid

ICD10 Fracture Code Components

• Location

• Laterality

• Closed, Open 1 or 2, Open 3

• Displaced or not

• Fracture pattern (long bones)

Generic Coding Aid Closed

Open Type I, II

Open Type III

Right

Left

Nondisplaced

Displaced

Transverse Oblique

Spiral Comminuted

Segmental

Diaphyseal

Humerus Radius Ulna

Femur Tibia Fibula

Metacarpal

1st Other

Base Shaft Neck

Metatarsal

1st 2nd 3rd 4th 5th

Clavicle

Sternal Shaft Lateral

Proximal Humerus

Parts: 2 3 4

Tuberosity: Gr Less

Distal Humerus

Supracondylar

Unicondylar

Medial Lateral

Olecranon

Intraarticular: Y N

Comminuted

Proximal Radius

Head Neck

Proximal Femur

Midcerv Basicerv

Head

Trochanter: Gr Less

Intertrochanteric

Distal Femur

Intraarticular: Y N

Unicondylar

Medial Lateral

Epiphyseal

Proximal Tibia

Bicondylar

Unicondylar

Medial Lateral

Spine Tuberosity

Ankle

Malleolar

Medial Lateral

Bi Tri

Maisonneuve

Distal Radius

Intraarticular: Y N

Patella

Tranverse Longitudinal

Comminuted

Pilon Acetabulum

Wall

Ant Post Med

Transverse

Pelvis

Stable: Y N

Ilium Pubic Rami

Ishium

Sacrum

Zone: 1 2 3

Displacement

Not Minimal Severe

Foot

Cuboid Navicular

Cuneiform

Med Middle Lat

Column

Anterior Posterior

Dome Other

Calcaneus

Intrarticular: Y N

Body Ant process

Avulsion

Talus

Neck Body Dome

Posterior Process

Great Toe Phalanx

Proximal Distal

Lesser Toe Phalanx

Proxi Middle Dist

Types of Encounter

• Initial – Closed (A), Type I or II (B), Type III (C)

• Subsequent – With …

• Routine healing (D,E,F)

• Delayed union (G,H,J)

• Nonunion (K,M,N)

• Malunion (P,Q,R)

• Sequela (S)

Two final words about ICD-10

Unspecified vs. Other

Questions

• Local bone graft use

• ROH during revision work

• Revision of a periprosthetic THA fx

• GT fx with RTC repair

• What is a “multiplanar” ex fix

• Modifier -22

• OR X-ray 0.17 RVUs

Questions

Presenting the Tip of the Iceberg

The World of Business

Quality happens at the point of production!

“Quality” surgical coding

• Adhere to the rules

• DONE AT THE TIME OF SERVICE

– BY THE OPERATING SURGEON

• Should be reviewed by a professional coder

• !Maximizes revenue!

Coding Pearls

• ORIF Syndesmosis 8.8 27829

• Antibiotic beads – Insertion 1.48 11981

– Removal 1.78 11982

– Exchange 3.30 11983

• WV placement 0.55 97605

• Secondary wound closure 12.04 13160

• Intraop stress view 0.41 77071

• Meniscal repair 8.62 27403

“We must continue to measure every act against not only what is legal but also what we would be happy to have written about on the front page of a national newspaper in an article written by an unfriendly but intelligent reporter. Sometimes your associates will say “Everybody else is doing it.” This rationale is almost always a bad one if it is the main justification for a business action. It is totally unacceptable when evaluating a moral decision. Whenever somebody offers that phrase as a rationale, in effect they are saying that they can’t come up with a good reason. It’s very likely that if a given course of action evokes such hesitation, it’s too close to the line and should be abandoned. There’s plenty of money to be made in the center of the court. If it’s questionable whether some action is close to the line, just assume it is outside and forget it.”

Warren Buffet Memo to Berkshire Hathaway Managers

July 26, 2010

We must continue to measure every act against not only what is legal but also what we would be happy to have written about on the front page of a national newspaper in an article written by an unfriendly but intelligent reporter. Sometimes your associates will say “Everybody else is doing it.” This rationale is almost always a bad one if it is the main justification for a business action. It is totally unacceptable when evaluating a moral decision. Whenever somebody offers that phrase as a rationale, in effect they are saying that they can’t come up with a good reason. It’s very likely that if a given course of action evokes such hesitation, it’s too close to the line and should be abandoned. There’s plenty of money to be made in the center of the court. If it’s questionable whether some action is close to the line, just assume it is outside and forget it.

Warren Buffet Memo to Berkshire Hathaway Managers

July 26, 2010

Front page test

“Everybody else is doing it”

There’s plenty of money in the center of the court.

What would your mother say?

Summary

• You are a surgeon • You are paid to do two things

– Think – Operate

• Surgery = primary source of revenue • Maximize revenue with ethical and correct

coding • Work hard & be smart • Become a coding expert