Coding and reimbursement in sports medicine.

Annotation: Dr. Filler has been in orthopaedic leadership positions for over 30 years, and in the national forefront of nomenclature and coding for over 20 years. He currently sits on the prestigious American Medical Association Current Procedural Terminology Editorial Panel. His summary 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 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 altered yearly. The CPT is developed by the AMA and the CMS. The changes from the previous year are listed in Appendix B. Many payors lag behind each year in converting their computers to the new codes and payment rules. It is unlikely the payor will reimburse you later unless you request a correction 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 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 problem and sent for therapy. The patient is then seen for a follow-up visit 2 weeks later, and there is no improvement. The shoulder is then injected. You must document in your records that the decision to inject was made only at the time you reexamined the patient and not before. Then code, for example, 99213 -25 and 20610. If your records state that on the initial visit an injection of the shoulder may be necessary but you will try therapy first, then only the injection code can be used and no E/M visit 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 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.