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Updated: Jun 18 2021

Clinical Billing

  • definitions
    • 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
    • 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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