definitions Overview coding and billing involves a system of rules and guidelines by which orthopedic surgeons can describe what was treated and in what manner it was treated Definitions Common procedural terminology (CPT®) a 5 digit alphanumeric code used by insurers to help determine the amount of reimbursement that a practitioner will receive for services provided Category I codes five-digit codes have descriptors which correspond to a procedure or service (range from 00100 - 99499) Category III codes provisional or temporary codes for emerging procedures Relative Value Units (RVU) a unit value assigned to each CPT code derived by four factors International Classification of Disease -10 (ICD-10) a clinical cataloging system developed by the World Health Organization (WHO) used to define and classify diagnoses ICD-10 ICD-10 provides coding structure to diagnosis alphanumeric seven-digit codes utilized allows description of: chronicity from acute to chronic phase of care initial, subsequent, sequela effects routine, complications, laterality left, right, unspecified Current Procedural Terminology (CPT) CPT codes are assigned to specific services including operative procedures, nonoperative care, and minor procedures (injections/aspirations) operative procedures codes are all-inclusive and include approach, procedure, closure, splinting, etc. codes are associated with a global period (0, 10, or 90 days) during which all associated services are considered within the package of care Modifiers a 2-digit code used to indicate a special situation -22 modifier unusually complicated due to increased technical difficulty, patient condition, time, effort -24 modifier unrelated E&M during the postoperative period -25 modifier significant or separate E&M performed on the day of the procedure Evaluation and Management (E&M) Location of service and level of service location outpatient new patient has not received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years established patient has received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years there is a 90-day post-operative period where all follow-up services are considered part of the global fee and cannot be billed separately consultation service requested by another physician advice must be the object of the request, not a transfer of care a request must be documented in the chart level of visit must be documented written response to requesting physician must be provided by consulting physician emergency department hospital initial care, continued care, consultation level of service (1-5) component-based history, examination, and medical decision making levels include problem focused, expanded problem focused, detailed, comprehensive billing level is limited to the lowest level of history, examination, or medical decision making time-based when visit consists mainly of counseling and coordination of care amount of time must be documented Documentation detail in note must match requirements for location and level of services that are billed for Global Period (90-Day) Overview single payment for care associated with a surgical procedure What is included preoperative care preoperative visits and work OR preparation (patient marking, positiong, prep, drape) operative care skin to skin work immobilization and bracing application of immobilization or bracing in the OR postoperative care inpatient visits (postoperative progress notes) postoperagive visits for up to 90 days whether performed by physician or physician extender What is not included postoperative care diagnostic tests and procedures (e.g., CBC on postop day #1) immobilization and bracing application of immobilization outside of the OR different conditions visits for separate problems evaluation by physician part of a different group additonal operations reoperation for complications from initial procedure (e.g., infection) staged procedures (e.g., front-back spine surgery) Coding errors ICD-10 diagnosis code should support and justify the corresponding E&M and CPT codes for services provided Errors seen as fraud regardless of whether intentional or unintentional services billed were not provided at all services billed were not provided by billing physician services billed were provided but not supported in documentation responsibility ultimately falls on the billing physician