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A Few Tips for Orthopedic Surgery Coding

Nov 12, 2019 | Posted by Jocelyn Gaddie in ASC Billing & Coding

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When coding for orthopedic surgery, properly understanding and translating documentation is vital.

Coding for treatments at your ASC can be complicated, especially those involving orthopedic surgeries. Correct orthopedic documentation translates into proper surgery coding, which will boost your revenue cycle and ensure efficient reimbursement. 

In this post, we address some of the most common orthopedic coding issues that can be tricky for ASCs, including shoulder and knee surgeries, trigger points, and spinal procedures as well as general tips and best practices.

Shoulder & Knee Surgery 

ASCs are increasingly performing shoulder and knee procedures, both repair and total joint replacement. The surgery codes for these procedures can be complicated, making it especially crucial for physicians to communicate and document all details with those responsible for coding. With shoulder surgeries, it’s important to pay close attention to whether the treatment performed should use bundled or unbundled surgery codes. For knee procedures, proper coding considers whether the physician performs single compartment or multiple compartment procedures.

A patient with a shoulder injury may require multiple treatments, either at the same time or separately. The physician may employ a procedure on a patient’s rotator cuff in addition to removing a small portion of the clavicle. This same patient may also need to be treated for labral tears, torn cartilage attached to the rim of the shoulder socket that helps keep the ball of the joint in place. 

In most knee surgery cases, multiple procedures are performed within a single compartment.  And in this instance, only the most complex procedure described in the procedure documentation should be coded. When the procedure note describes multiple procedures in different compartments of the knee, the most complex procedure in each compartment may be coded.

Because there are strict coding guidelines for shoulder and knee surgeries, make sure to review all documentation from the physician for each case. Your ASC must know if shoulder surgery codes should be bundled or unbundled. Additionally, for knee procedures, it’s necessary to know whether the surgery was performed within a single compartment or multiple compartments. The codes used for these procedures inform the insurance company about the patient's plan of care and the associated payment. 

Trigger Point Injections

It’s also crucial to pay close attention to trigger point cases, also referred to as “knots.” Knots can restrict the range of motion and make it difficult to perform daily activities. Studies show that trigger point injections (TPIs) decrease pain and improve function. Patients can have multiple sessions, each with a different number of injections.

As a result, TPI codes are especially complex, but no less important as they influence your company’s revenue cycle management. For trigger points, code by the muscle or muscles and injection or injections. For instance, there is a code for single muscles, multiple muscles, single injections, >2 injections, >5 injections. There are also codes for injections on the right or left side of the body.

In addition, the first time a physician administers a TPI, it is often for diagnostic reasons. For this reason, documentation must be very specific, stating which muscles were injected, how many times, the results of the pre- and post-injection on range of motion (ROM), as well as the strength, pain, and overall change of the patient.

Spinal Cases 

When dealing with spinal cases, remember that the levels, sides, and joints matter. An injury to the vertebrae can involve many different areas of the body. There could be damage to the spinal column, joints, discs, spinous or transverse processes, transverse multiple muscles or ligaments, foraminal openings, and even the ribs.

When completing the surgery coding for spinal procedures, you must understand the levels of the spinal cord. For example, a low back pain patient may be seen for L4 on L5, whereas a neck patient may be seen for C5 on C6. The “L” stands for “lumbar,” and the “C” stands for “cervical.”

There are more than 500 ICD-10 codes associated with the spine. To help navigate this vast and varied directory, review the following checklist:

  • What is the spinal level?
  • Were multiple levels involved?
  • Was the procedure unilateral, and if so, what side?
  • Was the procedure bilateral?
  • Was there imaging involved?
  • Was hardware involved?
  • For what joint was the procedure used?
  • Will there be follow-up procedures for this type of treatment?

Orthopedic Surgery 

When coding for orthopedic surgeries at your ASC, attention to detail is critical to your revenue cycle management. When scheduling these complex treatments — including surgery coding — make sure your team allows ample time to process coding to ensure that everything is documented correctly, down to the last modifier. It’s also a good idea to remain educated and updated on all ICD codes (including surgery codes) and procedures, as they are continually changing.

Audit Your Coding Performance

As part of your revenue cycle management, consider a comprehensive coding audit. Our team at in2itive offers a coding audit that reviews the details of your coding and billing processes. If your company falls outside of the acceptable error rate, we can work with you to identify areas of improvement and implement changes. Sign up for a free coding audit consultation today.


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