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Common Coding Mistakes in Ambulatory Surgery Centers: Orthopedic & Pain Management (Part 1 of 3)

Procedural coding errors can lead to lost revenue or unintentional upcoding at ambulatory surgery centers.

Stephanie Ellis, RN, CPC, is the president and owner of Brentwood, Tenn.-based Ellis Medical Consulting, and Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.

Here Ms. Jones and Ms. Ellis elaborate on seven trouble areas for coding orthopedic and pain management procedures.

1. Fracture debridement. Coders frequently do not recognize debridement of an open fracture, since it may be only a couple of words in the operative report. They should pay close attention to fracture care in case debridement is mentioned. If it's noted by the surgeon at all, it must be coded in addition to the fracture treatment, Ms. Jones says. The correct code to use is 11010, 11011 or 11012.

2. Tendon grafts with ACL reconstruction. The 20924 code for the harvest of a patellar or hamstring tendon graft is billable only when the graft is obtained from the opposite knee or from either ankle, Ms. Ellis says.

The current procedural guidelines state the graft must be "from a distance" when billed with the 29888 ACL repair code, which means the tendon graft cannot come from a separate incision in the same knee. Coders should be aware of where the graft came from.

"[This does] not constitute a far enough distance to bill for it separately, according to CPT guidelines, even though it is not unbundled in the CCI material and it is performed through a separate incision," she says.

3. External fixation. Most fracture treatment codes have been revised so external fixation has to be coded separately, Ms. Jones says. Coders often follow rules from years past, when external fixation was included and inadvertently lose revenue.

4. Sacroiliac joint injections. Sacroiliac joint injections can be confusing because of there are several variations used depending on the procedure and the payor. Coders should use 27096 — which documents the injection procedure for a sacroiliac joint, arthrography and/or anesthetic or steroid — when billing commercial payors or billing the physician's surgical service, Ms. Ellis says.

When billing Medicare for the same procedure, coders should use the CPT G0260, which documents the injection procedure for a sacroiliac joint. Imaging is included in both of these codes and should not be billed separately.    

However, if the joint injection is performed without fluoroscopic guidance or arthrography, coders should use 20610, injection into a major joint. The 20610 code does not include imaging and would be used by both the physician and the ASC facility for billing to all payors, she says.

5. Hardware or implant removals. Deep pin removals done in an ASC require the code 20680. The physician will have to make an incision to visualize the implant, but the code is only to be billed once per fracture or previously operative site, regardless of the amount of hardware removed or the number of incisions made, Ms. Ellis says. The code can only be billed twice if the surgeon removes an implant or hardware from a completely different surgical or anatomical area.

6. Nerve branch destruction. For pain management treatments, rather than reporting the destruction of each nerve branch separately, coders should be reporting based on each intervertebral joint destroyed, Ms. Jones says. Each joint is supplied by two nerve branches, so coding separately would double the cost of the bill. Physicians may balk if they used a separate needle for each nerve branch, but that does not change the coding.

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