What’s the difference between M51.09 and M51.04? It’s just one number, right? Well, for these two ICD-10 codes, that one number means the difference between a specified and unspecified code. It also likely means the difference between getting a first-pass denial on your claim from a payer and getting reimbursed.
That’s just one example of the seemingly countless coding nuances that your orthopedic practice has to be mindful of every day. These small nuances can have a big impact on the health of patients, physicians and entire practices.
Incorrect or underspecified documentation can result in surgery denials, unnecessary tests and mistaken procedures. It can also impact your bottom line as a result of inaccurate E/M levels and reimbursement, claim denials, and even audits.
With thousands of codes and constant rule changes, no one person can possibly keep up with the particularities of every payer. Being aware of the most common ones can help. Here are three coding complexities that we see often in the orthopedic practices we work with at Robin and how you can document them correctly.
Distinguishing between an uncomplicated and complicated acute injury or illness
According to the American Medical Association (AMA), an uncomplicated acute injury/illness is a recent or new short-term problem with a low risk of morbidity. There is little to no risk of mortality with treatment, and a full recovery without functional impairment is expected. It is a problem that is normally self-limiting or minor, but it is not resolving in a definite or prescribed way.
Examples of uncomplicated acute injuries/illnesses include:
- Cystitis
- Allergic rhinitis
- Simple sprain
The AMA defines a complicated acute injury/illness as a problem that is extensive, has treatment options that are multiple and/or associated with risk of morbidity, or requires treatment that includes evaluation of body systems that are not directly part of the injury.
Examples of complicated acute injuries/illnesses include:
- Head injury with a brief loss of consciousness
- Bone that is partially/completely fractured in any way
- Pain with no known injury, which an MRI reveals is a result of nerve damage that requires surgery
An intuitive way to help ensure you’re correctly distinguishing between an uncomplicated and complicated acute injury/illness is to ask yourself a series of questions while doing your documentation.
For an issue that appears to be uncomplicated, ask yourself:
- Will this issue heal on its own without intervention?
- If yes, you’re right. It’s most likely uncomplicated.
- Were there any other organ systems involved?
- If yes, it’s most likely complicated.
- Was there more than one treatment option available to the patient?
- If yes, it’s most likely complicated.
- Was the treatment option conversative?
- If it was an in-office procedure, it’s most likely uncomplicated.
- If it was a surgical procedure, it’s most likely complicated.
For an issue that appears to be complicated, ask yourself the following questions. If the answer to some or all of them is “yes,” it’s most likely complicated.
- Were there multiple non life threatening injuries addressed?
- Was there an evaluation of neurovascular or cardiovascular structures while examining a patient for a fracture?
- Was there a need to evaluate other body systems not related to the injury?
Identifying when an exacerbated chronic condition is severe
An exacerbated chronic condition is not a new problem, but an existing medical condition that is worsening and no longer stable or at a baseline.
Examples of exacerbated chronic conditions include:
- Osteoarthritis at 7/10 pain level
- Osteoporosis causing symptoms
- Psoriatic arthritis flares that are not severe
A severe exacerbated chronic condition is an existing medical condition that is extremely worse for which the patient is seeking immediate treatment. The condition is unbearable to the patient and may require hospital-level care and/or immediate surgery.
Examples of severe exacerbated chronic conditions include:
- Severe osteoarthritis
- Severe rheumatoid arthritis
A quick way to help determine if the exacerbated chronic condition you’re looking at categorizes as severe is to ask yourself, “If left untreated, is there a likelihood this patient may require hospital-level care?” If the answer is yes, it’s most likely severe.
Expanding the definition of low-risk treatment plans
The latest guidance from NGS Medicare, the AMA and the American Academy of Pediatrics shows it’s time to expand the definition of low-risk treatment plans.
There is currently no distinction between “minimal” and “low” risk of complications and/or “morbidity” or “mortality” of patient management. Together with our orthopedic partners, we at Robin are eliminating confusion and creating better consistency in our documentation.
Going forward, low-risk treatment plans should include all items that require minimal discussion and/or patient consent to improve compliance with the latest guidance and achieve a more accurate E/M.
For example, these plan items would now be considered low risk under this expanded definition:
- Imaging orders
- X-rays
- MRI with contrast
- MRI without contrast
- Lab orders
- Comprehensive metabolic panel
- Hemoglobin A1C
- Complete blood count
- Diagnostic studies
- Electromyography
- Electrocardiogram
- Nerve conduction study
- Other plan items
- Chiropractics
- Massage
- Physical therapy
- Occupational therapy
- Durable medical equipment
Putting your new coding knowledge into practice
When it comes to medical coding, there are always more complexities to cover, but hopefully knowing how to navigate these common issues will help you document them in the future.
Keeping up with the latest distinctions and definitions is clearly a challenge in its own right, but so is putting those changes into practice.
You have to tweak your finely-tuned routine, which often results in spending more time in the EHR documenting and asking yourself even more questions until eventually the change becomes second nature.
That is, until there’s another change.
At Robin, we’re reimagining how documentation gets done to truly eliminate the burden of administration for orthopedics. We hear from practices every day that documentation is burning out physicians and revenue cycle teams. That’s why we created our one-of-a-kind smart device, the Robin Assistant™.
The Robin Assistant records all the audio and video from the exam room, so we’re able to develop complete notes and codes for all your patient visits on your behalf behind the scenes. We then deliver all your documentation directly to the EHR for your review and signature.
Unlike any other documentation solution, Robin also focuses exclusively on supporting orthopedists. Our coding algorithm is always up to date with the latest payer rules for orthopedics, and our team behind the scenes is trained to document all the coding nuances and more. We also work very closely with your clinical staff and revenue cycle teams to ensure there is great collaboration and support for your practice at every step.
Visit robin.co to discover how Robin can streamline documentation across your entire practice and allow you to focus completely on patient care.