Broderick - Top Coding Tips in Fracture Care

Coding tips for Fracture Surgeons
2016
J. Scott Broderick, MD
Director of Orthopedic Trauma
Spartanburg Regional Hospital
Disclosures
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AO Speakers Bureau
OTA PM Committee Chair
SEFC Secretary/Treasurer
Reviewer JOT
• I have no conflicts associated with this presentation
Goals
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List the basic tenets of quality coding
Explain the rationale behind wRVU utilization
Be able to better navigate ICD-10
Gain a few pearls in coding for fracture care
Coding
Some Things
Never Change
Theory of Business
1. Reality
Reality is defined by the marketplace and goes wherever it
wishes.
2. Focus
Focus is achieved when the organization aligns itself with
reality.
3. Organizational Competencies
Once an organization is aware of the changes required, it
must identify and develop the skills and competencies
required to prosper over the long term
How can you increase revenue?
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Types of services
Payor mix
Contractual agreements
Effectiveness of billing & reimbursement
– CODING
The Correct Theory of Business
“Broderick style”
• Surgeons are paid for operating
• Those who pay us use codes to describe what we do
• Surgical coding is the most important “business skill”
you can develop
• Coding is rule-based and manageable
Coding
• Assumption
– Back office clerical function
– Low physician involvement
• Reality
– Critical core competency for all of healthcare
– Physician must be knowledgeable, informed, and
actively involved
Simplicity
Simplicity is the ultimate sophistication
“It takes a lot of hard work to make something
simple, to truly understand the underlying
challenges and complexities, and come up with
elegant solutions.”
“If you need slides, it shows
you do not know what you
are talking about.”
Slide 9
Choices
Resource Based Relative Value Scale
• Developed at Harvard SPH
• 1992 Medicare National provider payment schedule
• Each CPT is assigned a relative value
– Provider work (time & intensity)
– Practice expense
– Malpractice cost
• Geographic practice cost index (GPCI)
– Economic variation in the US
• Conversion factor
Total RVU (wRVU) examples
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TKA
THA
ACL Reconstruction
Meniscal Repair
CTR
Clavicle
IT nail
Tibial nail
Bimalleolar
Pilon (tib & fib)
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39.11
39.12
28.42
18.38
12.23
20.69
35.49
28.77
22.21
37.29
(20.72)
(20.72)
(14.30)
(8.62)
(4.97)
(9.69)
(18.18)
(14.45)
(10.62)
(18.43)
A typical day in the life of an
Orthopedist
• Trauma doc
– Slogs through a pilon ,
bimall ankle and IT hip fx
– ~7-8 hrs
• Joint doc
– 8 TKA/THA’s
– Flip rooms
• Because he/she is special
– ~8-9 hrs (or less)
• ~ 95 total RVUs
• ~ 47 wRVUs
• ~313 total RVUs
• ~166 wRVUs
Contract discussions
• Not total RVUs
– Usually wRVUs
• How are final RVU totals formulated
– CPT codes that are conflicted
– Concurrent codes are reimbursed at 50%
– Based on truly reimbursable codes
International Classification of Diseases
• US National Center for Health Statistics
– 1978 “Clinical Modification”
– Updated and revised annually
– Soon to be ICD-10-CM
• Used by all third party payors in US
• Four to seven digit code used to report illness, injury,
complaints,symptoms
– = diagnosis
– No code for “rule out”, “probable”, or “status post”
• World Health Organization
ICD-10
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THEORY
Increased specificity of
clinical information
More accurate
reimbursement
Improved quality of care
Better disease
management
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REALITY
Enormous disruptive
change to the health care
system
Dramatic effect on
revenue and operations
Significant administrative
burden
Benefits < cost ?
Interesting Y code Tidbits
• Y62-69
– Misadventures to
patients during
surgical or medical
care
• Y92.4 _ _
– Type of road for
accident
• Y90._
– Blood ETOH level
• Y92._ _
– Place of occurrence
– No “conservatory”
– Mobile home
swimming pool or
garage
• Y92.89
– Slaughter house
Systematic Approach
Courtesy of KZA
Coding Aid
Coding Aid
Coding Aid
Coding Aid
ICD10 Fracture Code Components
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Location
Laterality
Closed, Open 1 or 2, Open 3
Displaced or not
Fracture pattern (long bones)
Generic Coding Aid
Closed
Open Type I, II
Open Type III
Right
Nondisplaced
Left
Displaced
Diaphyseal
Humerus Radius Ulna
Femur Tibia Fibula
Metacarpal
1st Other
Base Shaft Neck
Proximal Humerus
Parts: 2 3 4
Tuberosity: Gr Less
Metatarsal
1st 2nd 3rd 4th
Transverse Oblique
Spiral Comminuted
Segmental
5th
Clavicle
Sternal Shaft Lateral
Distal Humerus
Supracondylar
Unicondylar
Medial Lateral
Olecranon
Intraarticular: Y N
Comminuted
Proximal Radius
Head Neck
Proximal Femur
Midcerv Basicerv
Head
Trochanter: Gr Less
Intertrochanteric
Distal Femur
Intraarticular: Y N
Unicondylar
Medial Lateral
Epiphyseal
Proximal Tibia
Bicondylar
Unicondylar
Medial Lateral
Spine Tuberosity
Ankle
Malleolar
Medial Lateral
Bi Tri
Maisonneuve
Distal Radius
Intraarticular: Y N
Patella
Tranverse Longitudinal
Comminuted
Pilon
Acetabulum
Wall
Ant Post Med
Transverse
Pelvis
Stable: Y N
Ilium Pubic Rami
Ishium
Sacrum
Zone: 1 2 3
Displacement
Not Minimal Severe
Foot
Cuboid Navicular
Cuneiform
Med Middle Lat
Column
Anterior Posterior
Dome Other
Calcaneus
Intrarticular: Y N
Body Ant process
Avulsion
Talus
Neck Body Dome
Posterior Process
Great Toe Phalanx
Proximal Distal
Lesser Toe Phalanx
Proxi Middle Dist
Types of Encounter
• Initial
– Closed (A), Type I or II (B), Type III (C)
• Subsequent
– With …
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Routine healing (D,E,F)
Delayed union (G,H,J)
Nonunion (K,M,N)
Malunion (P,Q,R)
• Sequela (S)
Two final words about ICD-10
Unspecified vs. Other
Questions
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Local bone graft use
ROH during revision work
Revision of a periprosthetic THA fx
GT fx with RTC repair
What is a “multiplanar” ex fix
Modifier -22
OR X-ray
0.17 RVUs
Questions
Presenting the Tip of the Iceberg
The World of Business
Quality happens at the point
of production!
“Quality” surgical coding
• Adhere to the rules
• DONE AT THE TIME OF SERVICE
– BY THE OPERATING SURGEON
• Should be reviewed by a professional coder
• !Maximizes revenue!
Coding Pearls
• ORIF Syndesmosis
• Antibiotic beads
– Insertion
– Removal
– Exchange
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WV placement
Secondary wound closure
Intraop stress view
Meniscal repair
8.8
27829
1.48
1.78
3.30
11981
11982
11983
0.55
12.04
0.41
8.62
97605
13160
77071
27403
“We must continue to measure every act against not only what is legal but also
what we would be happy to have written about on the front page of a national
newspaper in an article written by an unfriendly but intelligent reporter.
Sometimes your associates will say “Everybody else is doing it.” This rationale is
almost always a bad one if it is the main justification for a business action. It is
totally unacceptable when evaluating a moral decision. Whenever somebody
offers that phrase as a rationale, in effect they are saying that they can’t come up
with a good reason.
It’s very likely that if a given course of action evokes such hesitation, it’s too close
to the line and should be abandoned. There’s plenty of money to be made in the
center of the court. If it’s questionable whether some action is close to the line,
just assume it is outside and forget it.”
Warren Buffet
Memo to Berkshire Hathaway Managers
July 26, 2010
We must continue to measure every act against not only what is legal but also
what we would be happy to
have written
Front
page about
test on the front page of a national
newspaper in an article written by an unfriendly but intelligent reporter.
Sometimes your associates will say “Everybody else is doing it.” This rationale is
almost always a bad one if it is the main justification for a business action. It is
“Everybody else is doing it”
totally unacceptable when evaluating a moral decision. Whenever somebody
offers that phrase as a rationale, in effect they are saying that they can’t come up
with a good reason.
It’sThere’s
very likelyplenty
that if a given
course ofin
action
suchof
hesitation,
it’s too close
of money
theevokes
center
the court.
to the line and should be abandoned. There’s plenty of money to be made in the
center of the court. If it’s questionable whether some action is close to the line,
just assume it is outside and forget it.
What would
Warren Buffet
Memo to Berkshire Hathaway Managers
your mother say?
July 26, 2010
Summary
• You are a surgeon
• You are paid to do two things
– Think
– Operate
• Surgery = primary source of revenue
• Maximize revenue with ethical and correct
coding
• Work hard & be smart
• Become a coding expert