Coding Guidelines for Orthopedic Evaluation and Management

The orthopedic evaluation and management consist of 3 key components i.e., History; Physical Examination; and Medical Decision-Making (MDM). Additional components that may contribute to the level of service are counseling/coordination of care, the nature of the presenting problem, and time. So let’s understand every key component in detail.

History Component

The History component includes the chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and social history (PFSH) sections. A CC must be documented for every visit, and it is typically stated in the patient’s own words. The HPI uses descriptive elements to document the current problem(s). For non-Medicare patients, the CC and HPI must be obtained and documented by the physician who is the billing provider. For Medicare patients, physicians need to document that they have reviewed the information and verified whether it was obtained by assisting staff or via a patient portal.

Information pertaining to the ROS and PFSH sections may be recorded in the EHR by assisting staff or by the patient via a patient portal. The physician must attest to reviewing this information and comment on pertinent positive and negative responses. During follow-up visits, any changes, or lack thereof, should be documented with a date reference (if not automated by the EHR). The physician should review and agree with the data before then signing off electronically after each encounter.

The ROS involves an inventory of 14 body systems, focusing on descriptive symptoms (e.g., chest pain or shortness of breath) rather than diseases (e.g., heart attack or COPD [chronic obstructive pulmonary disease]). To receive credit from a payer for each body system, there must be an individual entry of a positive or negative response documented within the record. Note that this is an area of risk in an encounter with an established patient; you may not get credit from a payer for carrying forward ROS elements that are not pertinent to the presenting problem. The PFSH involves a review of 3 areas i.e., past, family, and social history. Pertinent positive or negative responses may be documented. Statements such as ‘non-contributory’ without further description are not acceptable.

Physical Examination Component

The second key component is the Physical Examination component. If we consider the example of Musculoskeletal, Musculoskeletal Single Specialty Evaluation includes both general examination elements and 6 musculoskeletal areas (neck, back, right and left upper extremities, and right and left lower extremities). Each area that is examined should be described in the report.

There are 5 specific examination components for each of the 6 musculoskeletal areas:

  • Inspection/Palpation (note malalignment, asymmetry, crepitation, osseous deformity, defects, tenderness, or masses or effusions),
  • Range of motion (note pain, e.g., with straight leg-raising, crepitation or contracture, and active and passive limits),
  • Stability (note laxity, subluxation/dislocation),
  • Muscle strength and tone (documented on a scale from 0 of 5 [complete atony] to 5 of 5 [full strength]; note atrophy, abnormal movements, flaccid, cogwheel, spastic, etc.), and
  • Skin (note scars, lacerations, ecchymosis, rashes, lesions, cafe-au-lait spots, ulcers, etc.). An examination of gait and station are also components of the musculoskeletal system assessment.

For a comprehensive examination, the other systems must be assessed if medically necessary like, constitutional (at least 3 of 7 vital signs and general appearance); cardiovascular (peripheral vascular examination, swelling varicosities, pulses, edema, etc.); lymphatic (nodes); and neurological/psychological (coordination, reflexes, sensation, orientation, and mood and affect).

Medical Decision-Making Component

The MDM component consists of 3 parts i.e., Data, Diagnosis, and Risk. These indirectly measure the complexity of the patient encounter. This component is considered more complex for patients undergoing multiple tests, with multiple diagnoses, and with multiple risk factors. The risk of treatment options as they pertain to the individual patient should be included here. In general, MDM is a metric of the workup performed by the physician to develop a medical diagnosis, while medical necessity should then validate the complexity of the MDM. This means that a healthy patient with a complex orthopedic problem, such as a fracture/dislocation, may still be considered lower complexity for the MDM than a patient with a chronic disease, such as emphysema or diabetes mellitus, who only requires straightforward orthopedic intervention.


Occasionally, time may be a factor in determining the level of service. This may influence CPT code selection if the visit predominantly consists of counseling and/or care coordination. In this instance, greater than half (50 percent) of the time spent face-to-face between the physician and the patient (not including non-providers) in an outpatient setting must consist of counseling and/or care coordination. The content of those activities must then be summarized in the documentation. Time spent reviewing records while the provider is not with the patient does not qualify. In addition, face-to-face time should be ‘rounded down’ in the documentation. The provider must include the following in their note: total face-to-face time, that >50 percent of the face-to-face time was spent counseling and/or coordinating care, and a summary of the discussion.

New and Established Patients

Determining whether the patient is new or established is the first step in the E/M coding process and relies on same-practice/same-specialty rules. Some of them are:

  • What is same practice? Any 2 physicians within a group are in the same practice, regardless of the location where the physicians practice.
  • What is the same specialty? In the instance of multispecialty groups, CMS has established specific specialty codes to define areas of specialization for health-care providers: orthopedics, hand, family practice, sports medicine, and podiatry are all distinct specialties, just as internal medicine, pediatrics, general surgery, etc., are distinct specialties. Orthopedic surgery, adult reconstructive surgery, trauma, spine, and pediatric orthopedics, however, all fall within the orthopedics specialty, as determined by specialty codes. A physician’s specialty is usually set during initial Medicare credentialing.

For physicians in a multispecialty practice (for example, orthopedic surgery, hand, family practice, internal medicine), a patient who has not been seen by a physician in the same specialty for 3 years is a new patient. A patient who has been seen by a physician (or NPP) in the same specialty, in the same group practice, within 3 years is considered an established patient.

For example, a patient who is seen by an orthopaedist (specialty code 20) who has not seen another orthopaedist (specialty code 20) within the same group during the last 3 years may be considered a new patient. Even if that patient saw a hand surgeon (specialty code 40), podiatrist (specialty code 48), or family practice sports medicine (specialty code 23) provider in the same group during the past 3 years, the patient is a new patient to the orthopaedist. We understand that some payers may choose not to recognize specialty code designations for the purpose of ‘new patient’ definitions.

If a patient sees a surgeon while carrying 1 insurance plan for a CC, and subsequently returns for a different or follow-up CC under a different insurance plan (within 3 years), the visit is considered to be that of an established patient. The 3-year rule for the same specialty/same practice applies even if the patient changes insurance plans.


CMS carriers, Part C Medicare plans, Medicaid, and some private payers do not accept consultation codes. While some private insurance carriers still allow consultation codes with specific requirements, some physicians have discontinued the use of consultations to simplify documentation and billing practice.

For a visit to be considered a consultation, 3 criteria must be met:

  • The requesting physician must be seeking advice from the consulting physician and not transferring care,
  • There must be documentation of a request from another provider in the patient’s record either by the requesting or consulting physician, and
  • The patient’s record must document that the consulting physician communicated the findings to the requesting physician via a separate report.

The process whereby a physician who is providing management of some, or all, of a patient’s problems, then relinquishes this responsibility to another physician without requesting an opinion is not considered a consultation. The physician transferring care is then no longer providing care for these problems, although he or she may continue providing care for other conditions when appropriate. If there is no request for consultation, then the visit is billed as a new or established patient visit, as appropriate.

The patient’s record must reflect communication of the orthopaedist’s findings in writing via a written report to the requesting provider. This is usually in the form of a letter summarizing the orthopaedist’s opinion that may accompany the standard office note and include summaries, findings, and recommendations on that consultation. For consultations, as with all categories of E/M, the documentation criteria for the level of service reported must be met.

The 3-year rule for new or established patients does not apply to consultations. As previously described, a primary care physician may ask the orthopaedist for a consultation on a patient’s foot problem, then a year later, ask for a second consultation on the same patient’s shoulder. Both visits may be reported as consultations, presuming all requirements for consultation are met. Follow-up visits with the orthopaedist for these problems are established visits.

Note that CMS and CPT rules on coding often differ and are complex and subject to interpretation. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. In this article, we shared coding guidelines for orthopedic evaluation and management for reference purposes only. Our sole intention is to assist orthopaedists with correct coding to minimize claim denials, delays, and potentially costly errors. If you need any assistance in orthopedic billing and coding, email us at: or call us at: 888-357-3226.

Published By - Medical Billers and Coders
Published Date - Nov-21-2022 Back

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