Orthopedic Surgery Coding Challenges: The Top 5 Common Errors in Orthopedic Procedure Codes

Procedure coding in Orthopedic Surgery is very essential to avoid loss of revenue which can affect the Revenue Cycle Management (RCM). With the implementation of the ICD-10 codes and the changing healthcare rules and regulations, orthopedic surgery procedure coding has become a challenge and affects medical billing which in turn impacts orthopedic revenues.

Procedure Codes for Orthopedic Surgery Billing:

1. Incorrect Codes:

Application of incorrect codes when related to fractures and their types can cause loss of revenue or claim denials/rejection. For example, when coding special attention needs to be paid to the debridement of an open fracture and the proper codes need to be employed for debridement as well as for treatment of the fracture. Very often coders forget to add the codes and revenue is lost. When one or more fractures occur and different surgical procedures are performed, all of the first procedures should be coded as initial encounters.

The 7th character should not be influenced by the order of the surgical procedures. Coders should remember that the “how it happened” external cause code should never be a first-listed code on a claim, but should be used on all additional claims for injuries where the incidence of initial versus subsequent or sequel is to be registered.

2. CPT Guidelines:

Coders need to be aware of the CPT guidelines and pay special attention to the wordings of the physician documentation.  This assumes significance especially when grafting is being done and the placement from where the graft has been lifted. So it is the coders who need to be updated with guidelines, rules & regulations when coding using physician documentation. Special attention should be paid to language.

3. Proper Anatomical Coding:

When it comes to removing hardware or implants, coders should remember to code the side well given that the code is only billed once for each operative site or fracture. Only when multiple anatomical areas are operated, then multiple code billings are employed.

For example, when performing arthroscopic procedures of the knee, if coders are aware of the anatomy, then knowledge of the compartment(s) where the physician performed the procedure will be crucial to coding. Specifying anatomical location and laterality is very essential for medical coders to help the medical billers bill correctly.

4. Arthritis Coding:

Pay special attention when coding for arthritis. There are no specific codes for primary and secondary arthritis. Unlike previously, now within secondary arthritis, there are specific codes for post-traumatic osteoarthritis and secondary osteoarthritis

5. External Fixation:

Codes for internal or external fixation are to be used only when internal or external fixation is not already listed as part of the basic procedure.

Thus, coders need to be updated and have knowledge of not just Medicare guidelines and regulations but also what changes private payers may have initiated. The entire coding and billing process is now a challenge for orthopedic coders and billers.

Orthopedic surgeons too when documenting should be careful and describe every action they perform so that coders should be able to apply the appropriate codes to help medical billers bill correctly to implement a healthy and profitable healthy revenue Cycle Management (RCM).