Coding: Not Sexy, Just Necessary

If given the choice between attending a seminar on coding or undergoing dental work, many orthopedic surgeons would choose the latter. Coding is one of those things that falls into the “not why I went to medical school category, ” and many view it as tedious and only peripherally relevant to a surgeon’s daily life. But one educated look at the balance sheet can motivate any physician to learn more.

Margaret M. Maley, B.S.N., M.S., a consultant with KarenZupko & Associates, has led coding seminars for the American Academy of Orthopaedic Surgeons (AAOS) for 13 years. Maley, who has not only kept her audiences awake, but knows how to convince them of the value of coding, states, “Orthopedic surgeons often want to run the other way when the issue of coding arises, which, of course, it does all the time. Every day in thousands of practices across the country surgeons are leaving money on the table because they either avoid or don’t fully understand coding.”

Maley, who obtained a masters degree in orthopedic nursing from Rush University, has worked with orthopedists for nearly 25 years, the last 15 of those being focused on the business aspects of the field. She observes, “The biggest mistake orthopedic surgeons make is that they don’t do their own coding, but instead, delegate it to a certified coder or front office person. Any certified coder would tell you, however, that unless the procedure has been properly documented in the record then they can’t code for it. So to have someone retrospectively looking at the documentation and trying to determine the appropriate code isn’t accurate because the documentation may not be correct.”

“But if a surgeon understands what needs to be documented then coding is not particularly difficult. The problem is that most surgeons don’t understand the intricacies of coding so they don’t know what needs to be documented. The bigger issue, however, is that they just don’t want to do it.”

Leaving Money on the Table

Setting the motivation issue aside temporarily, Maley gives examples of when understanding the value of documentation could make a difference. “If during a hip revision surgery you use bone graft, it is important to know that bone graft is not reportable for reimbursement unless you document that you harvest it through a separate incision. Even the certified procedural coder cannot report the codes for services unless they are properly documented. Surgeons who do revision surgery know the code for bone graft, but don’t know the importance of documenting that the graft was harvested through a separate skin or fascial incision. For example, let’s say the doctor is doing a meniscectomy and chondroplasty. If he or she does not document that the chondroplasty was done in a separate compartment of the knee, the chondroplasty is not reportable for reimbursement. Many surgeons may not understand this documentation nuance.”

Surgeons have a bent toward efficiency. “To have someone take the time to sit down, read the notes, and assign codes when the surgeon could do it in seconds, is just not a good use of staff time. Also, in most situations, surgeons know exactly what they will do in the OR, so they can do the coding beforehand. We suggest that the surgeon gives the business office diagnosis and CPT (Current Procedural Terminology) codes when a surgery is booked, ” states Maley.

Another way surgeons can ensure they have funds to pay the bills and meet any monthly economic surprises, says Maley, is to get clear on the importance of diagnosis coding. “This is another whole set of coding rules, which, unfortunately, relies on a book that isn’t user friendly. The ICD-9 system was not created for the purpose of reporting services…it was made for statisticians and adapted for physicians. The purpose of diagnosis coding is to communicate to payers the complicated nature of the patient you’re treating. Payers screen off the diagnosis code. For example, if someone comes in with a simple problem with no complicating factors and a high level evaluation & management code is reported, the payer will wonder about this discrepancy. ‘How can a simple problem require such a high level of service?’”

She continues, “Generally speaking, orthopedists are lax about assigning diagnosis codes if they’re not orthopedic in nature. And this will leave money on the table. For example, if someone in her 30s presents with numbness in the fingers, and has no other symptoms, the surgeon may consider carpal tunnel syndrome as a possible diagnosis. However, a different set of evaluative questions and physical examination would be in order if the same type of patient comes in, but is also an insulin dependent diabetic. If the orthopedic surgeon doesn’t document and submit the diagnosis code for insulin dependent diabetes then the payer will wonder why the more extensive history, examination, and medical decision making was necessary.”

“Sometimes payers reimburse for services rendered for a specific problem. For example, certain types of injections are only paid for if they are given in the knee as opposed to the shoulder. It is important to link the diagnosis code to the CPT service/procedure code. If, for example, a claim is sent in for an ACL repair, but the surgeon also did a meniscal repair, you will need a diagnosis for both on the claim ticket. An ACL repair doesn’t treat the problem of a meniscal tear so you must have another code. Not doing this properly lengthens the amount of time that it takes for collections, meaning, of course, that you don’t have the money in the bank to cover your bills.”

The Big Picture

For most orthopedists, the fun is found in the OR. Fixing fractures and righting rotator cuffs are exactly why they set out to become surgeons. But in the end, OR time is only part of the picture. “Careful documentation and correct coding for evaluation and management (E&M) services is critical, ” says Maley. “When orthopedists do not take into account the contribution of E&M services to their bottom line, they ignore a significant source of income. Most orthopedists are not inclined to pay attention to the business side of medicine, even if it’s surgically driven. So ignoring office related services is a common mistake.”

In today’s climate, says Maley, business offices are fighting harder than ever to get the appropriate reimbursement. “If the surgeon is actively involved in reimbursement it can free up the business office and coding personnel to work on getting the reimbursement that is due instead of poring over documents and assigning codes. Coders are very important and they need to be freed up from the basics of coding in order to do other things that impact the bottom line. These things include examining how reimbursement comes in, seeing if something is not paid properly, appealing claim denials, etc. Those are things the surgeon could not and would not do.”

Still skeptical? Put your research hat on and track reimbursements before and after you get involved in coding. You might be left wondering how much money you forfeited in the past.