Updated: 9/26/2020

Clinical Billing

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  • Overview
    • coding and billing involves a system of rules and guidelines by which orthopedic surgeons can describe what was treated and in what manner it was treated
  • Definitions 
    • Common procedural terminology (CPT®)
      • a 5 digit alphanumeric code used by insurers to help determine the amount of reimbursement that a practitioner will receive for services provided
        • Category I codes
          • five-digit codes have descriptors which correspond to a procedure or service (range from 00100 - 99499)
        • Category III codes
          • provisional or temporary codes for emerging procedures
    • Relative Value Units (RVU)
      • a unit value assigned to each CPT code derived by four factors
    • International Classification of Disease -10 (ICD-10)
      • a clinical cataloging system developed by the World Health Organization (WHO) used to define and classify diagnoses
  • ICD-10 provides coding structure to diagnosis 
    • alphanumeric seven-digit codes utilized  
      • allows description of:
        • chronicity
          • from acute to chronic
        • phase of care
          • initial, subsequent, sequela
        • effects
          • routine, complications, 
        • laterality
          • left, right, unspecified
Current Procedural Terminology (CPT)
  • CPT codes
    • are assigned to specific services including operative procedures, nonoperative care, and minor procedures (injections/aspirations)
      • operative procedures codes are all-inclusive and include approach, procedure, closure, splinting, etc.
      • codes are associated with a global period (0, 10, or 90 days) during which all associated services are considered within the package of care
  • Modifiers 
    • a 2-digit code used to indicate a special situation 
      • -22 modifier
        • unusually complicated due to increased technical difficulty, patient condition, time, effort
      • -24 modifier
        • unrelated E&M during the postoperative period
      • -25 modifier
        • significant or separate E&M performed on the day of the procedure
Evaluation and Management (E&M)
  • Location of service and level of service
    • location
      • outpatient  
        • new patient
          • has not received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years  
        • established patient
          • has received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years
          • there is a 90-day post-operative period where all follow-up services are considered part of the global fee and cannot be billed separately 
        • consultation
          • service requested by another physician
          • advice must be the object of the request, not a transfer of care
          • a request must be documented in the chart
          • level of visit must be documented
          • written response to requesting physician must be provided by consulting physician
      • emergency department
      • hospital
        • initial care, continued care, consultation
    • level of service (1-5) 
      • component-based
        • history, examination, and medical decision making
        • levels include problem focused, expanded problem focused, detailed, comprehensive
        • billing level is limited to the lowest level of history, examination, or medical decision making 
      • time-based 
        • when visit consists mainly of counseling and coordination of care
        • amount of time must be documented
  • Documentation
    • detail in note must match requirements for location and level of services that are billed for
Global Period (90-Day)
  • Overview
    • single payment for care associated with a surgical procedure
  • What is included
    • preoperative care
      • preoperative visits and work
      • OR preparation (patient marking, positiong, prep, drape)
    • operative care
      • skin to skin work
    • immobilization and bracing
      • application of immobilization or bracing in the OR
    • postoperative care
      • inpatient visits (postoperative progress notes)
      • postoperagive visits for up to 90 days
        • whether performed by physician or physician extender
  • What is not included
    • postoperative care
      • diagnostic tests and procedures (e.g., CBC on postop day #1)
    • immobilization and bracing
      • application of immobilization outside of the OR
    • different conditions
      • visits for separate problems
      • evaluation by physician part of a different group
    • additonal operations
      • reoperation for complications from initial procedure (e.g., infection)
      • staged procedures (e.g., front-back spine surgery)
Coding errors
  • ICD-10 diagnosis code should support and justify the corresponding E&M and CPT codes for services provided
  • Errors
    • seen as fraud regardless of whether intentional or unintentional
      • services billed were not provided at all
      • services billed were not provided by billing physician
      • services billed were provided but not supported in documentation
    • responsibility ultimately falls on the billing physician

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(OBQ11.256) A 32-year-old male is being seen in your office for evaluation of a possible rotator cuff tear. He has been seen in your office by one of your partners previously after surgical treatment of a femoral shaft fracture. How much time has to pass since last evaluation or treatment in your group for this patient to revert to a new patient under CPT guidelines? Tested Concept

QID: 3679

6 months




1 year




18 months




2 years




3 years



L 3 C

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(OBQ10.64) A patient undergoes closed reduction of a bimalleolar ankle fracture dislocation by the ER physician and is sent to your clinic for evaluation. You evaluate the patient and schedule him for surgery. According to the 2009 guidelines, which of the following scenarios would meet criteria for coding the encounter as a new patient? Tested Concept

QID: 3157

You injected his knee in the office almost 3 years ago for osteoarthritis, and have not seen him since




He had an arthroscopic operation by your partner 4 years ago




You were consulted 1 year ago for shoulder pain when he was hospitalized for chronic renal failure




He was seen by your partner in clinic for a herniated disk 2 years ago, but had no procedures performed




You performed a hip replacement on him 12 years ago, and his last follow-up was 18 months ago at which time he was doing well



L 2 D

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Evidence (2)
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