Coding has a clear and direct impact on any healthcare facility's financial success.
"Do not discount the importance of the coding process to the facility’s bottom line and how much money can be left on the table if whoever is doing the coding does not know what they are doing," says Stephanie Ellis, RN, CPC, Ellis Medical Consulting.
Also, if procedures are not coded properly, it can cause compliance problems for a facility, she notes. This can lead to a facility losing their accreditation and tarnishing their reputation.
1. Specificity in diagnoses. One of the most challenging is ascertaining the the specificity of the diagnoses on examination, which with a value-based reimbursement system becomes extremely important, says Maxine Lewis, CPC, CPC-I, CPMA. CCS-P, a member of the National Society of Healthcare Business Consultants.
"No only is the specificity of the diagnosis important, but physicians must add the 7th digit to the ICD-10 code to indicate if it is an initial, subsequent or sequelae encounter," she says.
She explains that the seventh digit of the ICD-10-CM code is as follows:
A = Initial encounter
D = subsequent encounter
S = sequela
2. Differences in guidance from Medicare and AAOS. Medicare and the American Academy of Orthopaedic Surgeons approach coding for shoulder surgery differently.
"It appears that the Medicare and the AAOS are not seeing eye-to-eye. Medicare considers the shoulder to be all one anatomical site, even though the AAOS considers the glenohumeral joint, the acromioclavicular joint and the subacromial bursa as separate anatomic areas," says Cynthia Keith, CPC, coding manager at Alpha II, a company focusing on developing coding and compliance software platforms and publications for healthcare professionals.
The difference means coders may need to approach their coding differently by payer. Know the guidelines applicable to your payer and code accordingly — for example, with Medicare, a code to be billed that is unbundled in the Medicare CCI edits, should not be billed to Medicare even if it is performed in a different area.
3. More codes are bundled now. A lot of the codes that were once unbundled and would normally be allowed — such as the 59 modifier, XP, XE, XS and XU modifiers — will now fall under scrutiny, Ms. Keith says. More codes are becoming bundled and cannot be unbundled.
For example, when coding a right arthroscopic rotator cuff repair with a distal caviculectomy, acromioplasty and debridement of the labrum, coders may be used to reporting:
• 29827 RT: Arthroscopy, shoulder, surgical; with rotator cuff repair RT side
• 29824 RT: Arthroscopy, shoulder, surgical distal claviculectomy including distal articular space surface (Mumford procedure),
• +29826 RT: Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty with coracoacrmial ligament (arch) release, when performed
• And 29822 RT- 59: Arthroscopy shoulder surgical; debridement limited distinct procedural service
"The problem with coding this is that 29822 bundles into 29827 and 29824 per NCCl edits and because it is the right shoulder for all procedures, it would be inappropriate to use a modifier to bypass the bundling edit," says Ms. Keith. "The ideal thing to do would be to find what CMS defines as different anatomical sites of the shoulder joint and what the AAOS defines."
It will become critical for providers and coders to document properly and know the requirements inside out.
For Medicare cases, you cannot bill the 29826 Arthroscopic Subacromial Decompression procedure because it is an "add-on code" that is considered a "packaged procedure" by Medicare that is not separately payable by Medicare, adds Ms. Ellis.
4. Synovectomy and shoulder manipulation billing. If a Synovectomy is done for visualization or approach — and not primarily done as a separate procedure with its own reason — it should not be billed, even if it is in a different area from another procedure.
If a shoulder manipulation is done in the same case with an arthroscopic shoulder procedure, it is not separately billable.
5. Billing for cases that start as "mini-open" and convert to open procedure. If a procedure starts out as a being performed through the arthroscope but then the surgeon makes an incision a "mini-open" procedure, and completes the procedure as an open procedure, only the code for the open procedure should be billed.