Ortho coding and billing

[SedRate]

I mainly work in the OR, so most of my clinic patients are established. I rarely code/bill for new patients. How do you guys go about billing your NEW patients? For example, let's say you get a new fracture patient. The decision making is at a level 4, but if you do a limited exam, you're billing at a level 2 or 3. I feel like there's money being left on the table but is this just the way it is in ortho? Thoughts?

 

(Edited for corrections.)

[Arthropathy]

You should include a general exam ie A&Ox3, no acute distress. You need minimum 12 total points from at least 2 systems, so a general exam + msk exam should get you to a level 3

[ventana]

Almost all the Ortho notes I see are so full of fluff and buff it is comical.....

 

Document what you did. Not what you need for a billing code

 

 

I always laugh when an otho note talks of CV/Resp exam...... I don't think there is a stethoscope to be found in the entire office.... :) (having fun)

 

Seriously, you are looking at one system, and to be billing higher complexity codes for looking at a sprained ankle is sort of ridiculous.... keep it simple and fast - hence why some Ortho see 40+ patients a day...

 

Instead of trying to upcode each visit, learn now to do injections and additional items that might benefit the patient and the bottom line..

[SedRate]

You should include a general exam ie A&Ox3, no acute distress. You need minimum 12 total points from at least 2 systems, so a general exam + msk exam should get you to a level 3

Right, I actually do a general, skin, and detailed MSK, so those visits do actually code at a level 3, my mistake. I guess I was actually comparing a level 3 and level 4, not 2 and 4. Fracture care meets level 4 for MDM but the history and physical don't.

[AbeTheBabe]

An ortho exam should easily be level 3 from my understanding.

 

General - A&Ox3, no acute distress.

Skin - Normal with no erythema/edema/ecchymosis.

MSK - Document AROM/PROM, pain to palpation, strength, special tests.

 

It's very hard to get to a level 4 for a new patient, and even if you do level 4 there is a question of if it was medicall necessary. I'd stick with level 3 for new patients and level 4 for established if you give an injection, recommend surgery, manage their NSAID, etc.

[SedRate]

Almost all the Ortho notes I see are so full of fluff and buff it is comical.....

 

Document what you did. Not what you need for a billing code

 

 

I always laugh when an otho note talks of CV/Resp exam...... I don't think there is a stethoscope to be found in the entire office.... :) (having fun)

 

Seriously, you are looking at one system, and to be billing higher complexity codes for looking at a sprained ankle is sort of ridiculous.... keep it simple and fast - hence why some Ortho see 40+ patients a day...

 

Instead of trying to upcode each visit, learn now to do injections and additional items that might benefit the patient and the bottom line..

Not trying to upcode. Just making sure I'm not downcoding. For the example I used in the original post, my coder mistakenly downcoded it at a level 2, so I'm glad I posted this and realized the mistake. Otherwise, I would've left money on the table ;-) The problem was corrected.

 

And the example in question was a fracture, not a sprained ankle.

[rev ronin]

Is the patient breathing normally and unlabored? Sclera anicteric? Adequate dentition? A+O? Walks with normal gait and balance? How about normal speech, affect, and thought process?

 

Remember, you just need ONE ELEMENT from a system to count that system, and there's nothing I'm aware of that says an 'exam' has to involve touching the patient.  I'd never document "RRR, normal S1+S2, no MRG" if I didn't auscultate the chest, but I can document "no peripheral edema, no clubbing of digits" with a quick glance.

 

A sprained ankle is a 99204 medical decision making level for a new patient under the '95 rules if you prescribed e.g. Naproxen 500 mg bid x7d.  Get a good H&P, including what you document you reviewed off of the patient intake form, and it's a solid 99204.

 

Upcoding is a pejorative term.  There are really only two things possible: downcoding, and fraud.  If you say you did it and you didn't do it, that's fraud, including if you copied it forward from a previous note unchanged but didn't actually address it at that visit.  If you did it, but don't claim it because you think it's not REALLY that level of a visit, you've instead downcoded.

[AbeTheBabe]

The question is do you need the 8 system physical to diagnose a sprained ankle? In other words, was your exam medically necessary? As long as you can justify that, then 99204 is fine.

[rev ronin]

The question is do you need the 8 system physical to diagnose a sprained ankle? In other words, was your exam medically necessary? As long as you can justify that, then 99204 is fine.

To diagnose a sprained ankle? Probably not, no.  To reasonably assure myself and the patient that nothing else immediately serious was going on? Sure.

[goose37]

Never bill a level 4 new? Because a stethoscope is the only way a heart/pulm status could be determined. Pulses regular rhythm? Vitals show normotensive without tachy/brady. Can walk back from x-ray without breathing heavy? Coughs throughout exam from the recent PallMall? Motor/sensory exam along the extremity? Understands and can repeat the postoperative plan?

Medically necessary...Yea, I think if they're having surgery those things ought to be known. And yes if a patient comes in hypotensive and tachy and leaves the clinic and dies, chances are someone may start asking questions about their clinic note.

I understand a bone carpenter couldn't possibly carry the knowledge of a previous practice owner, but possibly you may need an orthopedic visit someday.

[cg02186]

This is a pretty informative thread as I'm a new grad that begins my first job as an Ortho PA in two months! I'm currently on my second Ortho elective rotation and I always document multiple systems to get everything as I just figured that's being thorough.

 

General: A&O x 3 in NAD

Skin: No eccymosis, rash, or edema present

Neuro: Equal sensation bilaterally L1-S2 dermatomes. DTR normal.

Vascular: Distal pulses 2+ bilaterally PT, DP

 

Then a detailed MSK exam.

 

If I'm rounding on a post op patient I'll listen and document breath sounds, if wound appears clean, dry, intact. If bowel sounds are present, have they had bowel movement, etc.

 

Is that a reasonable documentation set for most Ortho patients for a level 3? I'm still trying to learn and assume I'll get more formal training once I start but trying to get on top of it.

[SedRate]

An ortho exam should easily be level 3 from my understanding.

 

General - A&Ox3, no acute distress.

Skin - Normal with no erythema/edema/ecchymosis.

MSK - Document AROM/PROM, pain to palpation, strength, special tests.

 

It's very hard to get to a level 4 for a new patient, and even if you do level 4 there is a question of if it was medicall necessary. I'd stick with level 3 for new patients and level 4 for established if you give an injection, recommend surgery, manage their NSAID, etc.

From what I've gathered as I've looked into this a little more, you need 12 bullet points from two different systems on your exam or 6 bullets from two systems to hit level 3 for a new patient. Your example above currently has 8.

[SedRate]

To diagnose a sprained ankle? Probably not, no. To reasonably assure myself and the patient that nothing else immediately serious was going on? Sure.

And that's why I posted it in the orthopedic category. I wanted to gauge how orthopedists handled their new patients -- do you perform a detailed exam or stick with a problem-focused exam?

 

On a occasion, I'll get an ER referral patient without a PCP who has something else wrong besides their injury. If it's something I'm comfortable treating, then I treat it and refer them to a nearby PCP for follow-up.

[rev ronin]

From what I've gathered as I've looked into this a little more, you need 12 bullet points from two different systems on your exam or 6 bullets from two systems to hit level 3 for a new patient. Your example above currently has 8.

Sounds like the 97 criteria. 95 is still valid.

[SedRate]

Sounds like the 97 criteria. 95 is still valid.

I'll have to look into the '95 criteria.

[rev ronin]

I'll have to look into the '95 criteria.

They're a lot easier to hit and substantially less complicated as far as medical risk goes, per the coursework my SP had us all review.  Again, they're still valid, and I've even seen some things describing how you can mix '95 and '97 criteria on the same visit... but I'm about at the end of my own personal knowledge.