Medical coding may only contribute to 5% of denials throughout the revenue cycle; however, these denials are entirely preventable. These mistakes affect revenue flow, necessitating claim appeals, delaying reimbursement or causing issues when coding audits are performed to determine level of coding compliance and accuracy.
Sidestep these common mistakes, get it right the first time, and keep the revenue flowing smoothly in your orthopedic practice. Here are five directions to implement!
Improper 7th character in the ICD-10 code
Pre-assigning diagnosis for suspected illness or injury
Failure to report T-code
Inattention to parenthetical notes
Overusing laterality modifiers
Medical coders, billers, and practice managers, keep reading to learn how to remove these common problems from your workflow!
When choosing an ICD-10 code, you need to review documentation and choose the correct 7th character to reflect coding to the highest specificity.
For example:
Your provider documents that patient returns for follow-up care of an intraarticular fracture of right distal radius, S52.571D,(D). They denote subsequent encounter for closed fracture with routine healing.
X-rays at the visit reveal a nonunion.
You will need to change the 7th character to reflect the nonunion. S52.571K,(K) denotes subsequent encounter for closed fracture with nonunion.
Pay close attention to the documentation given in those fracture follow up visits to stay on top of accurate ICD 10 reporting.
Avoid assigning a diagnosis code when the documentation from the provider only states that the injury or illness is “suspected,” “likely,” or “probable.” This especially includes a diagnosis that the provider ordered testing to rule out or confirm.
This requires careful review of documentation to look for signs/symptoms of injury or illness. You should assign the proper ICD-10 for the sign/symptom if the documentation states no definitive diagnosis has been given. After the initial consultation, wait until test reports are obtained.
For example:
When a patient complains of knee pain and swelling following a twisted knee injury while skiing, the provider may state he suspects an ACL injury.
The provider will need to order an MRI to confirm the presence of a “suspected” tear.
Assign the proper ICD-10 to capture the sign/symptom, which is knee pain and swelling (M25.561/.562 and M25.461/462), not an ACL tear.
It’s common for coders to fail to report an ICD-10 code from chapter 19 in the ICD-10 coding manual, which covers “Complications of surgical and medical care, not elsewhere classified.”
For example:
A patient presents for pain and instability in her hip.
The x-ray shows the presence of total hip arthroplasty with loosening of one of the components.
You’ll need to refer to the T-codes in chapter 19 to assign the proper code that reflects the complication: T84.030A/.031A, mechanical loosening of internal hip prosthetic joint, initial encounter based on laterality.
Failing to give attention to the parenthetical notes following some of the CPT codes can result in inaccurate reporting and claim denial for bundling procedures.
For example:
There is a parenthetical note following CPT codes 20552 and 20553 which identify patient care involving trigger point injections.
These codes state these procedures cannot be reported with 20560 and 20561 for the same muscle(s).
A second parenthetical note states that if imaging guidance is performed, see procedure codes 79642, 77002, 77021.
Laterality modifiers are widely used in orthopedic coding to ensure coding to the highest specificity. In certain coding scenarios, however, laterality modifiers are not needed. One of those being when the CPT code definition states “bilateral”.
Take a look at CPT code 73521— radiologic examination for hips, bilateral, with pelvis when performed; 2 views. Appending RT or LT to this CPT will cause an automatic claim rejection or claim denial.
The key takeaways for avoiding these common mistakes for orthopedic services are to read and comprehend the CPT code definitions! Pay particular attention to the parenthetical notes. It is helpful to highlight and asterisk in your coding book to draw your eye to those details. You can even draw an arrow from the specific code down to the corresponding parenthetical notes.
Read and familiarize yourself with ICD-10 coding guidelines and highlight key areas. Be on the lookout for direction of which 7th character to assign based on each category of codes and documentation provided.
It always comes down to documentation from your provider, so be sure to assign definitive diagnosis codes when documented and don’t assign signs/symptoms when “suspected” or “probable” terms are used. Look for “complications” in documentation and this will help direct you to assigning the proper T-code for the most accurate code reporting.
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