Coding and reimbursement in sports medicine.

Annotation: Dr. Filler has been in orthopaedic leadership positionsfor over 30 years, and in the
national forefront of nomenclature andcoding for over 20 years. He currently sits on the prestigious
AmericanMedical Association Current Procedural Terminology Editorial Panel. Hissummary
thoughts and current insights are described here.
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Payment for medical services has become increasingly complex due to confusing government
regulations and extensive penalties for misbilling. The Inspector General for Medicare is authorized
to assess a penalty up to $10,000 for each submitted CPT (Current Procedural Terminology)
code that is miscoded or upcoded. Insurance carriers other than Medicare are now following the
lead of the government and have been permitted legally to extract similar penalties. The
Department of Health and Human Services (HHS) Center for Medicare and Medicaid Services
(CMS) reported that in 2001, miscoding and upcoding by providers represented 62% of the fraud
and abuse total of $8 billion annually. It is important for physicians, physical and occupational
therapists, trainers, and others involved in providing services for athletes to learn to code
and document accurately to avoid time-consuming and potentially devastating financial acupuncture
northwest ohio consequences.
It is important for each provider of medical services to athletes to attend one of the many courses
available for instruction in the International Classification of Diseases (ICD) and CPT coding.
The following discussion covers only some of the most frequent errors or omissions.
* CPT 2004: Use only the most recent American Medical Association(AMA) CPT coding edition. CPT
codes are added, deleted, or alteredyearly. The CPT is developed by the AMA and the CMS. The
changes fromthe previous year are listed in Appendix B. Many payors lag behind eachyear in
converting their computers to the new codes and payment rules.It is unlikely the payor will
reimburse you later unless you request acorrection and/or resubmit properly.
* Correct language: Your patient records should show what was done during your encounter with
the athlete and it is best to use ICD and CPT language. There is no ICD code for a hip pointer. Call it
a thigh contusion (924.00). Code it as ankle strap, not an ankle wrap (29540).
* Code your own: Many studies have shown the provider should code their own encounters and
procedures. The average loss in income where someone other than the provider codes is 25%. Only
the surgeon and the examiner can know what was done.
* E/M code incidence: HHS and other third-party payors have a file on each provider, and can graph
by computer how often an evaluation and management (E/M) encounter code is used. They would
like to see a bell-shaped curve of charges, where the middle codes are most frequently used and the
end (eg, 99201 and 99205) the least used. If your graph has a spike in the higher codes only, and
uses only one or two codes, you can expect an audit. The CMS fraud literature specifically
has identified this type of coding for special review. There are some legitimate providers, usually in
universities, that only see the most complicated of cases, and correctly use only the higher-level
codes. There are not many, however. Have your office tabulate how often you use different codes
and then make your own graph.

* Modifier -25: The use of CPT modifier -25 has had a confusing history, and until recently has not
been universally accepted. This modifier is attached to the E/M code when there is
identified "significant, separately identifiable evaluation and management services by the same
physician on the same day of the procedure or other service." The best example is a patient who is
seen for an examination of a sore shoulder and then has an injection into a painful shoulder bursa.
If this is a new patient or a patient who presents with a new complaint, the documentation is
obvious This Site that an examination was necessary to make the diagnosis before the injection
treatment. This is ICD coded usually as a subdeltoid bursitis (726.19) and the injection of the
shoulder bursa (20610). Depending on the history, physical examination, and decision-making tests,
this E/M visit is usually either a 99202 or 99203 code.
* The problem emerges when a patient is seen for a shoulder problemand sent for therapy. The
patient is then seen for a follow-up visit 2weeks later, and there is no improvement. The shoulder
acupuncture points for constipation is then injected.You must document in your records that the
decision to inject was madeonly at the time you reexamined the patient and not before. Then
code,for example, 99213 -25 and 20610. If your records state that on theinitial visit an injection of
the shoulder may be necessary but you willtry therapy first, then only the injection code can be used
and no E/Mvisit code.
* Counseling/time: Occasionally you will have an encounter with an athlete and family members
where the history, physical examination, and decision-making indicate a specific CPT code, but with
an encounter time much longer than usual due to lengthy explanations. Correct CPT coding can
increase reimbursement in these instances. The amount of time "counseling" must be documented.
The reasons why must also be documented in the patient's record.
* Example: A 15-year-old star high school baseball pitcher is seen again for a swollen, painful, and
stiff pitching elbow. The radiographs show enlargement of the medial epicondyle and apparent bone
fragments. The E/M visit for similar follow-up encounters would normally be 99213. However, when
it instead becomes advisable to immediately stop pitching, immobilize the arm, and most likely force
the athlete to switch to another baseball position, the family is unaccepting. In addition, the athlete
will soon qualify for a scholarship based on his pitching ability. The next 30 minutes of that
encounter are spent in an emotional discussion on arthritis, pitcher's elbow, radiograph review
etc. CPT states the average 99213 visit takes 15 minutes, but the total time with this patient and
family was 45 minutes. You can code 99215 since the average time for this level E/M visit is 40
minutes. Even though the work was level 3, the time increased it to level 5.
* Consultations: CPT states that "a consultation is a type of service provided by a physician whose
opinion or advice regarding evaluation and/or management of a specific problem is requested
by another physician or other appropriate source." To submit a code for outpatient consultations,
the consultant must document in the patient's record who requested the consultation. The
correct consultation code must be acupuncture for dogs used depending on the level of
history, physical examination, and decision-making (eg, 99243) and a written letter must be sent to
the requesting physician outlining the diagnosis and recommended treatment. The consulting
physician can take over the care of the patient and still code for a consultation. If the
consultant agrees to take over the care of the patient before examining the patient, then no
consultation code can be submitted. Presently Medicare only recognizes use of consultation codes
by physicians, and not by other healthcare providers.

* Explanation of benefits (EOB): Each payor has different rules relating to coding. If your charges

are being denied, review the EOB. It is important to determine why your charges are being denied.
This may be an indication your billing is being reviewed or you are coding incorrectly. Physicians
must monitor their denials. The payor can be wrong.
* Future: Presently the AMA and CMS are revising the documentation rules for E/M coding.
Physicians have not accepted the CMS rules for counting points and bullets, and have convinced
CMS these rules interfere with time for patient care. An alternative method of documentation for
E/M coding currently being developed will rely on clinical examples for all level 3 and 5 codes, and
all other levels will be extrapolated. Selected specialties have recently submitted examples of
clinical encounters. These examples will be reviewed by many groups. If implemented, it is
projected these new rules will not be in effect until, at the earliest, 2005 or 2006. No matter what
changes are eventually regulated, the rules will be based on the present system, and enlarged.
Time spent learning them now will be well spent.
Whenever I climb I am followed by a dog called 'Ego'. --Friedrich Nietzsche
Accepted May 21, 2004.
Resources
1. American Medical Association. CPT 2003. Available at http://www.ama-assn.org.cpt.
2. Department of Health and Human Services. Federal Register, Part II. December 31, 2002.
3. Web page for Medicare and Medicaid Services (CMS): http://cms.hhs.gov.
Blair C. Filler, MD
From the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles,
CA.
Reprint requests to Blair C. Filler, MD, 2300 South Flower Street, Suite 200, Los Angeles, CA
90007-2660.
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