Orthopedics

Feature Article Supplemental Data

Coding Education in Residency and in Practice Improves Accuracy of Coding in Orthopedic Surgery

Max R. Greenky, MD; Brian S. Winters, MD; Meghan E. Bishop, MD; Elizabeth L. McDonald, BA; Ryan G. Rogero, BS; Rachel J. Shakked, MD; Steven M. Raikin, MD; Joseph N. Daniel, DO; David I. Pedowitz, MD, MS

Abstract

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1–3), senior residents (PGY 4–6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380–383.]

Abstract

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1–3), senior residents (PGY 4–6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380–383.]

The goal of an orthopedic surgery residency training program is to produce surgeons who are self-sufficient and proficient in the practice of orthopedic surgery. Modern medicine dictates that orthopedic surgery graduates not only be proficient in the care of patients but also in systems-based practice management, because it is now a required milestone put forth by the Accreditation Council for Graduate Medical Education (ACGME).1 This includes a curriculum emphasizing accurate medical coding as an important part of this education.

Billing for patient encounters is performed by applying a complex set of rules to the Evaluation and Management (E/M) and Current Procedural Terminology (CPT) codes, with their appropriate modifiers when applicable. Numerous studies have shown that residents across different fields do not receive adequate education on these rules and are therefore ill-prepared when entering practice.2–8 Specifically, most orthopedic surgery residents receive little or no training at all in coding during their residency.9–12

Mistakes in coding can have negative ramifications on one's practice. Not billing the appropriate codes for a physician's services can lead to financial loss, and it can also result in billing too much or too little and therefore be considered fraud.13 With this in mind, it is crucial that orthopedic surgery residents have a basic knowledge in how to code properly for procedures and patient encounters.

The purpose of this study was to determine (1) how well orthopedic residents code when compared with practicing orthopedic surgeons and (2) whether medical coding education is associated with an improved billing accuracy for both. The authors hypothesized that prior coding education would lead to better performance in orthopedic clinical coding.

Materials and Methods

Institutional review board approval was obtained prior to beginning this study. A mock coding survey was developed using commonly encountered clinical scenarios by orthopedic surgeons and residents in both the inpatient and outpatient settings (Table A, available in the online version of the article). The 25-question examination, which included 6 clinical scenarios and additional independent questions, was developed in a multiple-choice format by 2 orthopedic surgeons (R.J.S., D.I.P.), both of whom have greater than 10 years of practice experience, then distributed electronically via the Research Electronic Data Capture (REDCap, Vanderbilt University, Nashville, Tennessee) system to orthopedic surgery residents post-graduate (PGY) 1 to 6 and attending orthopedic surgeons at 2 different training programs.14 The examination was not timed. Participants were asked to use CPT reporting rules and not specific payer policies when responding to questions. Participants were also instructed to refrain from discussing the scenarios with other examination takers and from using any assistive coding tools. Participation in the survey was entirely voluntary.

Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.Mock Coding Examination.

Table A.

Mock Coding Examination.

Results were analyzed in 3 groups: junior residents (PGY 1–3), senior residents (PGY 4–6), and attending surgeons. Overall and subcategory scores were recorded. Subcategory scores included (1) type of visit (n=11 questions), (2) modifiers (n=2), (3) E/M (n=7), and (4) CPT code identification (n=5). In addition to the examination, participants were asked if they had ever received various forms of coding education during their training or career, including a formal coding/billing education lecture as part of a residency curriculum, outside live course, American Academy of Orthopaedic Surgeons (AAOS)-sponsored event, or online education, or whether they were self-taught without a formal lecture.

Overall and subcategory scores were compared among the levels of experience (junior residents, senior residents, and attending surgeons) using Kruskal–Wallis H tests. Mann–Whitney U tests were performed to compare the impact of prior formal coding education resources on all scores. Pearson correlations were used to analyze the influence of orthopedic residency year on overall and subcategory scores. Spearman correlations were conducted to examine the effect of attending surgeons' years of practice on all scores.

Results

There were 67 total participants, comprising 28 (41.8%) junior residents, 24 (35.8%) senior residents or fellows, and 15 (22.4%) attending surgeons. The average number of years in practice for the attending surgeons was 13.1 years (range, 4–39 years).

Practicing surgeons performed significantly better than both junior (P<.001) and senior (P<.027) residents overall and in all subcategories, with a mean overall correct response rate of 72.8%, 47.4%, and 51.0%, respectively (Tables 12). There was no difference in the overall scores between junior and senior residents (P=.242). The only significant difference between resident groups was seen in the modifier category (P=.017), with senior residents outperforming junior residents.

Coding Examination Mean Scores by Experience Level

Table 1:

Coding Examination Mean Scores by Experience Level

Coding Examination Subcategory Mean Scores by Experience Level

Table 2:

Coding Examination Subcategory Mean Scores by Experience Level

Eighteen (34.6%) residents and 10 (66.7%) attendings reported having some form of formal coding education. Any form of education in coding was associated with a significantly improved overall score in both resident categories (54.4% vs 46.2%, P=.013) and a nonsignificant increase for attending surgeons (74.8% vs 68.8%, P=.390) (Table 3). Participants who reported attending a live coding course (n=9) performed significantly better overall and in all 5 subcategories (P<.026) than those who did not, whereas those who had a formal lecture (n=26) performed better than those who had not on overall score, type of visit scores, modifier scores, and CPT coding scores (P<.015). Participants who reported going to an AAOS-sponsored coding event (n=5) had significantly better scores in the modifier (P=.045) and CPT code (P=.027) subcategories only. No participants reported receiving online coding education. Those reporting being self-taught (n=12) had a significantly lower overall score (49.0% vs 61.7%, P=.018) than those receiving some form of formal coding education (n=28).

Influence of Formal Coding Education on Mean Overall Examination Scores

Table 3:

Influence of Formal Coding Education on Mean Overall Examination Scores

There was no correlation between attending surgeon years in practice and performance on the overall examination (P=.861, r=0.049) or in any specific sub-category (P>.105). However, there was a correlation between year in residency and increased performance overall (P<.001, r=0.618) and in all subcategories (P<.003, r>0.370).

Discussion

Knowledge of coding and medical billing practices is necessary to be able to properly document and charge for patient services. Although systematic and rule based, many surgeons find coding burdensome and spend little time learning its nuances. Although many physician practices have a dedicated staff that oversees charge submissions, having an understanding of how to code appropriately can improve efficiency and ultimately lead to a higher collection rate. An introduction to these skills during residency and fellowship can help prepare new surgeons for coding in their own practice, but often, little emphasis is placed on this during the postgraduate years. This leaves most knowledge to be gained during the transition from residency to practice.

Using a mock coding survey, the authors found that most residents performed poorly in identifying appropriate billing codes and modifiers. This is consistent with other specialties.15,16 Because of this, there is documented desire among orthopedic residents to receive formal coding education during their training. At the American Orthopaedic Association resident leadership forum in 2005, they reported an overall inadequate education in practice management and called for more, including coding.11 Despite this, using a 2006 survey sent to all graduating orthopedic surgery residents, Gill and Schutt9 reported only 13% were confident they could begin coding appropriately in their own practice. Miller et al10 also found that coding was ranked the second highest in functional knowledge deficiency.

These results are consistent with other studies in the literature and illustrate that a formal coding education in residency can significantly improve coding accuracy.10,15–18 In the current study, residents who received any form of coding education scored 54% correct vs 46% in those who had no formal education. This marginal increase in scoring following coding education shows that although coding education improves accuracy in coding among residents, the optimal form of education is yet to be determined. Further research into this topic may help elucidate this.

This study had limitations. With a small number of participants in each category (28 junior residents, 24 senior residents, and 15 attending surgeons), it is possible that the study was underpowered to detect certain differences that may have been present. The authors also did not stratify attending surgeons by subspecialty within orthopedics. It is possible that attendings could have performed better within their area of subspecialty. Nonetheless, attending surgeons still performed better across all areas of the examination.

Conclusion

This study highlights valuable findings regarding the role of coding education in residency and its continued lack thereof in today's programs. The authors have demonstrated that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. This, combined with the desire of orthopedic surgery residents for education in coding, suggests that they can benefit from formal education in medical billing in order to enhance their ability to correctly code when beginning practice.

References

  1. Milestones by specialty. ACGME.org. https://www.acgme.org/What-We-Do/Accreditation/Milestones/Milestones-by-Specialty. Accessed December 2, 2018.
  2. Adiga K, Buss M, Beasley BW. Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement: a national needs assessment survey of internal medicine residents. J Gen Intern Med. 2006;21(5):466–470. doi:10.1111/j.1525-1497.2006.00428.x [CrossRef] PMID:16704389
  3. Balla F, Garwe T, Motghare P, et al. Evaluating coding accuracy in general surgery residents' Accreditation Council for Graduate Medical Education procedural case logs. J Surg Educ. 2016;73(6):e59–e63. doi:10.1016/j.jsurg.2016.07.017 [CrossRef] PMID:27886974
  4. Bang S, Bahl A. Impact of early educational intervention on coding for first-year emergency medicine residents. AEM Educ Train. 2018;2(3):213–220. doi:10.1002/aet2.10102 [CrossRef] PMID:30051091
  5. Fakhry SM, Robinson L, Hendershot K, Reines HD. Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg. 2007;194(2):263–267. doi:10.1016/j.amjsurg.2006.11.031 [CrossRef] PMID:17618817
  6. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg. 2008;196(6):878–881. doi:10.1016/j.amjsurg.2008.08.008 [CrossRef] PMID:19095103
  7. Kapa S, Beckman TJ, Cha SS, et al. A reliable billing method for internal medicine resident clinics: financial implications for an academic medical center. J Grad Med Educ. 2010;2(2):181–187. doi:10.4300/JGME-D-10-00001.1 [CrossRef] PMID:21975617
  8. Murphy RF, Littleton TW, Throckmorton TW, Richardson DR. Discordance in current procedural terminology coding for foot and ankle procedures between residents and attending surgeons. J Surg Educ. 2014;71(2):182–185. doi:10.1016/j.jsurg.2013.07.005 [CrossRef] PMID:24602706
  9. Gill JB, Schutt RC Jr, . Practice management education in orthopaedic surgical residencies. J Bone Joint Surg Am. 2007;89(1):216–219. doi:10.2106/00004623-200701000-00029 [CrossRef] PMID:17200329
  10. Miller DJ, Throckmorton TW, Azar FM, Beaty JH, Canale ST, Richardson DR. Business and practice management knowledge deficiencies in graduating orthopedic residents. Am J Orthop (Belle Mead NJ).2015;44(10):E373–E378. PMID:26447414
  11. Ranawat AS, Dirschl DR, Wallach CJ, Harner CD. Symposium. Potential strategies for improving orthopaedic education: strategic dialogue from the AOA Resident Leadership Forum Class of 2005. J Bone Joint Surg Am. 2007;89(7):1633–1640. PMID:17606803
  12. Stautberg EF III, Romero J, Bender S, DeHart M. Orthopaedic resident practice management and health policy education: evaluation of experience and expectations. Cureus. 2018;10(4):e2461. doi:10.7759/cureus.2461 [CrossRef] PMID:29900081
  13. Medicare Program Integrity Manual. CMS.gov. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html. Accessed December 2, 2018.
  14. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381. doi:10.1016/j.jbi.2008.08.010 [CrossRef] PMID:18929686
  15. Ghaderi KF, Schmidt ST, Drolet BC. Coding and billing in surgical education: a systems-based practice education program. J Surg Educ. 2017;74(2):199–202. doi:10.1016/j.jsurg.2016.08.011 [CrossRef] PMID:27651049
  16. Pulcrano M, Chahine AA, Saratsis A, Divine-Cadavid J, Narra V, Evans SR. Putting residents in the office: an effective method to teach the systems-based practice competency. J Surg Educ. 2015;72(2):286–290. doi:10.1016/j.jsurg.2014.09.001 [CrossRef] PMID:25312297
  17. Varacallo MA, Wolf M, Herman MJ. Improving orthopedic resident knowledge of documentation, coding, and medicare fraud. J Surg Educ. 2017;74(5):794–798. doi:10.1016/j.jsurg.2017.02.003 [CrossRef] PMID:28258939
  18. Wiley KF, Yousuf T, Pasque CB, Yousuf K. Billing and coding knowledge: a comparative survey of professional coders, practicing orthopedic surgeons, and orthopedic residents. Am J Orthop (Belle Mead NJ).2014;43(6):E107–E111. PMID:24945481

Coding Examination Mean Scores by Experience Level

LevelOverall ScoreVersus Attendings (P)
Junior-level resident (n=28)47.4%.001a
Senior-level resident/fellow (n=24)51.0%<.004a
Attending (n=15)72.8%-

Coding Examination Subcategory Mean Scores by Experience Level

LevelType of Visit (n=11)Modifier (n=2)CPT (n=5)E/M (n=7)
Junior-level resident (n=28)49.4%57.1%37.1%49.0%
Senior-level resident/fellow (n=24)49.6%77.1%45%50%
Attending (n=15)66.7%96.7%70.1%77.1%
Attending vs residentP<.001aP=.004aP<.001aP<.001a

Influence of Formal Coding Education on Mean Overall Examination Scores

QuestionResponseOverallPResidents/FellowsPAttendingsP
Any formal coding education lecture?Yes62.0%<.001a54.4%.013a74.8%.390
No49.6%46.2%68.8%
As part of residency curriculum?Yes57.7%.12554.8%.002a82.0%.350
No53.1%46.3%71.4%
As part of outside live course?YesNANANANAb76.0%.195
NoNANA68.0%
As part of AAOS-sponsored event?Yes67.2%.05754.0%.42976.0%.773
No53.4%48.9%72.0%

Mock Coding Examination.

Instructions: Complete the multiple-choice questions to report the services reportable for reimbursement. To the best of your abilities, please use CPT reporting rules and not specific payer policies. Evaluation & Management services (E/M) only require that you list the “category of service” (new, established, consult, etc.) and not the level of E/M visit. The test is not timed; however, please refrain from discussing scenarios with other test takers and avoid the use of assistive coding tools (i.e. Codex or other materials).
Please select one of the following that describes you best:___Intern ___PGY2 ___PGY3 ___PGY4 ___PGY5 ___Fellow ___Attending
Do you speak English as a first language?___Yes ___No
Have you had a formal lecture in coding/billing?___Yes ___No
Is the coding/billing education part of: (Please check all that apply)___ Residency curriculum ___ Outside course (live) ___ AAOS sponsored event (live) ___ On-line Education ___ No formal education but self-taught
Scenario 1A.R. is a 27-year-old male rugby player with no past medical or surgical history who sustained a direct blow to the left leg and presents to your emergency room with leg pain and deformity, you are called to evaluate the patient by the ER. On examination, his compartments are soft, his skin is intact, he has good pulses, and normal motor and sensory exams. The remainder of the examination is unremarkable and he has no other complaints on questioning. His radiographs are pictured below.
After a discussion of treatment options, and risks, informed consent is obtained for open reduction internal fixation. The patient is taken to the operating room that evening for intramedullary nailing of the tibia without fibula fixation and the application of a short leg splint.
1. The evaluation and management service reported by you in the emergency room is:

New Patient Visit

Established Patient Visit

Outpatient Consultation

Inpatient Consultation

Initial Hospital Care

Subsequent Hospital Care

Emergency Room Visit

2. What modifier should be appended (if any) to the evaluation and management service above?

Increased Procedural Services-Modifier 22

Decision for Surgery-Modifier 57

Staged or related procedure or service by same physician during post op period-Modifier 58

Distinct Procedural Service-Modifier 59

No additional modifier necessary

3. Select the most appropriate code(s) and necessary modifier(s) from the bank to report the services in the operating room later that same evening.

Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage-CPT 27758

Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage-CPT 27759

Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal fixation, when performed; of tibia only-CPT 27827

Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction-CPT 27752

The patient complains of pain in the recovery room which is initially relieved with increasing doses of narcotic. However, throughout the night the patient's pain worsens despite elevation of the extremity and loosening of the bandage. By the next morning his pain is unbearable. Upon examination, his compartments are tense, and he has begun to experience “numbness between some toes”. He is diagnosed with compartment syndrome and taken back to the operating room emergently for four compartment fasciotomy. Following this surgery, the patient's numbness resolves as well as his pain. The remainder of his hospital course is unremarkable and he is discharged home in stable condition on postoperative day three.
4. Select most appropriate code(s) and necessary modifier to report the services described above.

Decompression fasciotomy, leg; posterior compartment(s) only-CPT 27601 AND Distinct Procedural Service-Modifier 59

Fasciotomy four compartments-CPT 27602 AND Distinct Procedural Service-Modifier 59

Decompression fasciotomy, leg; posterior compartment(s) only-CPT 27601 AND Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period-Modifier 79

Fasciotomy four compartments-CPT 27602 AND Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period-Modifier 79

Scenario 2T.S. is a 7 year old boy who fell off of the monkey bars and landed on an outstretched hand. He was seen in an urgent care center over the weekend for pain and deformity of his left arm. He was told he had a fracture, placed in a splint and instructed to follow up in your office first thing Monday morning. He has not been seen by you or anyone in your group in the past 3 years. On exam, his skin is intact, compartments soft, and his neurovascular status is intact. He has an obvious deformity to his left forearm. His x-rays from the urgent care show a both bone forearm fracture (below). You counsel his parents that his fracture is displaced and that it will need to be treated with a closed reduction the next day. The risks are reviewed and informed consent obtained.
5. The evaluation and management service reported by you at the visit is:

Established outpatient visit

Outpatient consultation

New Patient Visit

Emergency room consultation

6. What modifier should be appended (if any) to the evaluation and management service above?

Staged or related procedure or service by the same physician during the postoperative period-Modifier 58

Distinct Procedural Service-Modifier 59

Decision for Surgery-Modifier 57

Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period-Modifier 79

T.S. undergoes a closed reduction under general anesthesia the following day and a splint is applied. X-rays demonstrate satisfactory alignment.
7. Select most appropriate code(s) and necessary modifier(s) to report the services described above.

Closed treatment of radial and ulnar shaft fractures; with manipulation-CPT 25565 AND Application short arm splint (forearm to hand)-CPT 29125

Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation-CPT 25605 AND Application short arm splint (forearm to hand)-CPT 29125

Closed treatment of radial and ulnar shaft fractures; with manipulation-CPT 25565 AND Application long arm splint (shoulder to hand)-CPT 29105

Closed treatment of radial and ulnar shaft fracture; with manipulation-CPT 25565

Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation-CPT 25605 AND Application long arm splint (shoulder to hand)-CPT 29105

T.S. is seen back in the office at 2 weeks post-op. The cast is removed, x-ray are ordered and reviewed, and a new long arm cast is applied. Radiographs demonstrate acceptable alignment with callous formation. A separate signed x-ray report is documented in the record.
8. Select most appropriate code(s) and necessary modifier(s) from the bank to report the services described above.

Post-op visit in the global period-CPT 99024

No service is reportable for reimbursement-CPT X

Post-op visit in the global period-CPT 99024 AND Forearm, 2 views-CPT 73090

Post-op visit in the global period-CPT 99024; Forearm, 2 views-CPT 73090; AND Application of long arm splint (shoulder to hand)-CPT 29105

No service is reportable for reimbursement-CPT X AND Forearm, 2 views-CPT 73090

Scenario 3L.W. is a 64-year-old female with a past medical history of hypertension, hypothyroidism, type II diabetes and morbid obesity (BMI 41) who is sent to you by her primary care doctor for evaluation of progressive left knee pain. The patient has private insurance. The patient has not been evaluated by you in the past, but 2 years ago had an ORIF of her right wrist by your partner. She states she has taken nonsteroidal anti-inflammatory medication and they are no longer providing her any relief. She now requires a cane for ambulatory assistance. Left knee exam reveals a valgus knee with a mild effusion and an obvious limp with ambulation. There is palpable crepitus and range of motion is limited to 5–90 degrees with pain throughout. Evaluation of the contralateral side show no effusion and range of motion 0–125 degrees. AP Lateral and skyline view of the left knee ordered and taken in the office reveal tricompartmental DJD. A separate x-ray report was dictated and signed. You explain the risks, benefits and alternatives to total knee arthroplasty and encourage weight loss. The patient explains that she is trying to lose weight but the knee pain makes it difficult for her to exercise and sleep. You discuss steroid injection and discuss the risks and benefits. The patient gives informed consent and you inject 40mg of Kenalog in 4cc of 1% Lidocaine into the patient's left knee. The patient is instructed to follow-up on an as needed basis for her knee pain. A letter back to the requesting provider is dictated and sent.
9. The evaluation and management service reported by you at the visit is:

New Patient Visit

Established Patient Visit

Outpatient Consultation

Inpatient Consultation

Initial Hospital Care

Subsequent Hospital Care

Emergency Room Visit

10. Select most appropriate code(s) and necessary modifier(s) to report the services described above.

Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance-CPT 20600 AND Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service-Modifier 25

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance-CPT 20610 AND Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service-Modifier 25

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance-CPT 20610

Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance-CPT 20600 AND Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period-Modifier 24

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance-CPT 20610 AND Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period-Modifier 24

L.W returns to your office 6 months later. She states she got excellent relief from the joint injection but symptoms have returned. She has lost 4 pounds and has no additional complaints. She is going on a cruise and would like another injection you inject 40mg of Kenalog into the patient's left knee.
11. The evaluation and management service reported by you at the visit is:

Initial outpatient visit

Established patient visit

Outpatient consultation

New Patient Visit

Bill injection only, cannot bill for E&M encounter

Initial Hospital Care

Emergency Room Visit

Scenario 4R.R. is a 48 year-old female who presents in clinic for her a follow up visit after a left sided L5 microdiscectomy. She is 11 weeks post op. and states she has almost complete resolution of her preoperative symptoms of radiating pain down her left lateral calf to the dorsum of her left foot and was noted to be full strength on manual muscle testing bilaterally. She has no complaints related to her back. However, she reports she sustained a fall on ice this morning while getting the mail and landed on her right wrist. Examination of her right wrist shows mild swelling with no point bony tenderness. She is neurovascularly intact. AP Lateral x-rays of the right wrist were ordered and taken in the office. The documentation in the medical record concerning the x-rays state “x-ray revealed no fracture, good wrist and carpal alignment, reasonable bone density”. She is given a cock-up wrist splint. You plan to see her back in 4 weeks.
12. The evaluation and management service reported by you at the visit is:

Initial outpatient visit

Established outpatient visit

Outpatient consultation

Postoperative Visit

Inpatient Consultation

Initial Hospital Care

Subsequent Hospital Care

13. Select most appropriate code(s) and necessary modifier(s) from the bank to report the services described above.

Increased Procedural Services-Modifier 22

Unrelated E&M post-op-Modifier 24

Separate service-Modifier 25

Distinct Procedural Service-Modifier 59

No additional modifier necessary

Scenario 5A 42-year-old male presents to the emergency room after a slip and fall on ice. His past medical history is only significant for hyperlipidemia and hypertension. Imaging is obtained and a consult is placed to orthopaedic surgery. The patient is seen by the resident only on call and is determined to have a trimalleolar ankle fracture with <10% of the posterior malleolus involved. After an intra-articular ankle block, a closed reduction is performed and a splint is applied. Post-reduction imaging reveals anatomic reduction and the patient is discharged from the emergency room to follow up with the on-call orthopaedic surgeon the following week.
14. Select most appropriate code(s) and necessary modifier(s) to report the services described above for the on call surgeon.

Post-op visit in the global period-CPT 99024

No service is reportable for reimbursement-CPT X

Post-op visit in the global period-CPT 99024 AND Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service-Modifier 25

No service is reportable for reimbursement-CPT X AND Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service-Modifier 25

The attending physician sees the patient in the clinic 4 days later. New x-rays are ordered and read by the orthopaedic surgeon during the office visit. The patient is scheduled for an open reduction and internal fixation of his ankle at a later time.
15. Select most appropriate answer to report the services described above.

New Patient Visit

Established Patient Visit

Outpatient Consultation

Inpatient Consultation

Initial Hospital Care

Subsequent Hospital Care

Scenario 6R.D. is a 56-year-old male who presents to the emergency department with severe back pain that radiates down his lateral thighs to his anterior legs. He has 5 out of 5 muscle strength throughout his lower extremities, has normal reflexes, and has no upper motor neuron findings. He denies bowel or bladder incontinence. The emergency department orders an MRI scan which reveals moderate to severe central stenosis of the spinal canal from L4 to S1. You are consulted by the ER physician and you go to the ER to evaluate the patient. After examining the patient, you recommend a short course of oral steroids and physical therapy with outpatient follow up.
16. Select most appropriate answer to report the services described above.

New Patient Visit

Outpatient Consultation

Inpatient Consultation

Initial Hospital Care

Subsequent Hospital Care

Emergency Room Visit

After 3 months of non-operative treatment, R.D. complains of progressive and debilitating pain. Musculoskeletal exam is repeated and unchanged from the above. Additional examination reveals a carotid bruit bilaterally and a cardiac consultation is requested. You explain the risks involved in surgery and the patient elects to undergo operative management in the form of a posterior lumbar laminectomy from L4 to S1. A Consult with cardiology is scheduled and surgical date is given.
17. Select most appropriate answer to report the services described above.

New Patient Visit

Established Patient Visit

Outpatient Consultation

Inpatient Consultation

Initial Hospital Care

Emergency Room Visit

One week before the surgery, the patient returns to the office as she has questions about the proposed operation. Cardiac consultation and labs are reviewed, informed consent obtained and orders are written.
18. Select most appropriate code(s) and necessary modifier(s) to report the services described above.

Post-op visit in the global period-CPT 99024

No service is reportable for reimbursement-CPT X

Post-op visit in the global period-CPT 99024 AND Increased Procedural Services-Modifier 22

No service is reportable for reimbursement-CPT X AND Increased Procedural Services-Modifier 22

Independent Questions:
19. A level 4 Follow-up Patient evaluation and management service requires:

Documentation that at least two problems are being evaluated.

With regard to History, Examination and Medical Decision Making 2 of the 3 be documented at the same level.

History, Examination, and Medical Decision Making be documented at the same level.

A letter is sent back to the patient's primary care provider.

20. A level 3 New Patient evaluation and management service requires:

Documentation that at least two problems are being evaluated.

With regard to History, Examination and Medical Decision Making 2 of the 3 be documented at the same level.

History, Examination, and Medical Decision Making be documented at the same level.

A letter is sent back to the patient's primary care provider.

21. The coding and documentation of services provided to a patient is

The responsibility of the provider reporting the service for reimbursement.

The responsibility of the certified coder.

The responsibility of the non-physician provider (RN, PA, NP, etc.,) working with the physician.

A joint responsibility of the certified coder and the provider reporting the service for reimbursement.

22. Which statement about an office consultation service is FALSE:

The request for the consultation should be documented.

A copy of the physician's note must be sent to the requesting provider.

Separate documentation (other than the office note) should be sent to the requesting provider.

History, Examination, and Medical Decision Making should be documented at the same level.

23. List the following statement that is TRUE.

One can look at the diagnosis code and determine the level of evaluation and management service that should be reported for reimbursement.

The documentation of a medically necessary history, exam and medical decision making determines the level of E&M service reported for reimbursement.

The longer the documentation, the higher the level of evaluation and management service that should be reported for reimbursement.

There is no clinical scenario that would justify an orthopedic surgeon reporting a level 5 E/M service for reimbursement.

24. If there is no CPT code that describes the surgical service provided, the surgeon should:

Report the service that most nearly describes the service provided

Report an Unlisted Code from the same body area

Report the general orthopedic unlisted code

Write to the AAOS to have a new code listed

Report the service that most nearly describes the service provided with an additional 87 modifier.

25. The history of present illness can be documented by:

The patient.

The non-physician provider (RN, PA, NP, etc.) working with the physician.

The provider reporting the service for reimbursement.

All of the above

Answers: 1. E, 2. B, 3. B, 4. D, 5. C, 6. C, 7. D, 8.D, 9.C, 10.B, 11.E, 12. B, 13. B, 14. B, 15. A, 16. F, 17. B, 18. B, 19. B, 20. C, 21. A, 22. C, 23. B, 24. B, 25. D
Categories: 1. Type of Visit, 2. Modifier, 3. CPT, 4. CPT, 5. Type of Visit, 6. Modifier, 7. CPT, 8. E/M, 9. Type of Visit, 10. CPT, 11. Type of Visit, 12. Type of Visit, 13. E/M, 14. E/M, 15. Type of Visit, 16. Type of Visit, 17. Type of Visit, 18. E/M, 19. Type of Visit, 20. Type of Visit, 21. E/M, 22. E/M, 23. Type of Visit, 24. CPT, 25. E/M
Authors

The authors are from Rothman Orthopaedic Institute (MRG, BSW, MEB, ELM, RGR, RJS, SMR, JND, DIP) and the Lewis Katz School of Medicine at Temple University (ELM, RGR), Philadelphia, Pennsylvania.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: David I. Pedowitz, MD, MS, Rothman Orthopaedic Institute, 925 Chestnut St, 5th Fl, Philadelphia, PA 19107 ( drpedowitz@yahoo.com).

Received: August 24, 2019
Accepted: October 21, 2019
Posted Online: September 03, 2020

10.3928/01477447-20200827-10

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