General Workflow
If there are numerous WQ errors that seem out of the ordinary (shouldn't be occurring) what steps should be taken?
What is:
1. Gather multiple examples
2. Submit IS ticket with manager attached
What are the consultation requirements?
What is:
1. Request from referring provider
2. Render report
3. Send report back to referring provider
When should A, D, and S be used for Diagnosis codes?
What is:
A: initial encounter, is used while the patient is receiving active treatment for the injury
D: subsequent encounter, is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase
S: sequelae, is used for complications or conditions that arise as a direct results of an injury
Which provider has a separate taxonomy from the rest of the Orthopaedic department?
What modifier signifies that 2 surgeons are working together as primary surgeons performing distinct part(s) of a procedure?
What is 62 modifier
What are the current WQ expectations? (CRWQ)
What is:
1. 100% surgical charges
2. Consultations
3. Teaching Physician Requirements
4. New vs. Established
5. E&M (low vs. high level E&M)
How can we identify whether a patient is new vs. established in Epic?
What is: Filtering the patient chart by Department to filter by the Orthopaedic department
Can a Sequelae diagnosis code be used as a primary diagnosis for a service?
No- Sequelaes are complications or conditions that arise as a direct result of an injury. The complication or condition resulting from the injury must be coded first.
Surgeon performed a repair of a nonunion with bone graft harvested via a separate incision. Can CPT code 25431 and 20902 be billed together if the surgeon obtained the bone graft from a distant site via a separate incision.
What is: In this specific case NO. 25431 code descriptor includes the bone graft.
Otherwise, if a graft is obtained via a separate incision and is not inclusive to the code definition, or is not inclusive to a typical procedure, the bone graft may be reportable in addition to the primary procedure.
When is modifier 59 appropriate?
What is: Under circumstances to indicate that a procedure or service was distinct or independent from other non-E&M services performed on the same day. (E.g. separate site/ organ system, encounter, provider, incision/excision, separate lesion, or separate injury)
Where would one find links to resources (hint: Gold standard resources) available for research?
What is: Gold Standard Resource(s) Document located in the New Hire Training Binder
The APP sees a Medicaid patient and asks the MD a question regarding the treatment plan. What information should be reviewed for billing/ documentation per the APP billing workflow?
What is:
1. Documentation that the physician documented an attestation of the medical decision they made the same day
2. Ensure that the visit is billed with the service/ billing provider as the physician and the SA modifier is removed.
Is it okay to code the sign/ symptom along with the confirmed condition for the office visit?
During a routine post-op check during the global period of an excision of a soft tissue tumor the surgeon notes that the patient has some fullness and performs a superficial incision and drainage in the office. Should the I&D be billed? If so should it be billed with modifier 58 or 79?
If the payor follows CMS- this is not separately reportable:
Modifier 79 is typically reserved for an ‘unrelated’ procedure/ service at a different location. The seroma is secondary to the surgical intervention—thus if there had not been surgery, there would not be a seroma.
Modifier 58 is incorrect as this is not a planned procedure, is not more extensive, and is not part of the treatment plan.
When would modifier 57 be used or modifier 25?
What is: Modifier 57 is utilized when a decision for surgery is made the day before or day of a 90 day global procedure. Modifier 25 is utilized when a 0/10 day global procedure is performed on the same day as a significant, separately identifiable E&M
How do we work encounters in CRWQ that have edits in BOTH the registration and coding Ortho WQ?
The APP sees a patient in the hospital (inpatient). The physician physically sees and examines the patient on the same date of service and documents the exam and medical decision making. What type of visit does this support?
What is: A shared visit
What is the best format to grab providers attention when sending an in-basket around a diagnosis code?
What is:
WHAT: what the request is regarding
WHY: why the request is important
Can a surgeon separately bill for an osteotomy of the femur, tibia or fibula during arrest of the epiphyseal?
What is:
NO.Per AAOS this is included in the global services package of this code.
When an E&M is performed during the global period of a procedure due to complications of the procedure is it separately billable?
What is: No- complications of the procedure are included in the global package per CMS. However, underlying conditions or unrelated conditions are allowed to be separately billed during the global period with modifier 24 appended.
Is there a way to verify patient class?
What is: Yes- go to Hospital Account Maintenance to verify the patient class that the hospital billed.
If a provider discharges a patient on the same date of service BUT their total amount of time was less than 8 hours. What is the appropriate type of code?
What is: Initial observation code ONLY. No discharge code should be reported on a stay that is less than 8 hours.
99234-99236 should ONLY be used on stays that are at least 8 hours on the same date of service.
Bonus: UHC requires documentation of time of observation (H&P/ Discharge note) AND documentation of observation status (e.g. observation admit order)
What are a few examples of diagnosis driven CPT codes?
What is:
1. Open treatment of ulnar styloid fracture
2. Closed treatment of femoral shaft
3. Open treatment of humeral condylar fracture
During arthrodesis can a surgeon also separately bill for a head halter traction? (E.g. halo)
True or False. A separate note is required in order to bill for an assistant surgeon.
What is False. Documentation of services the assistant surgeon performed is required but a separate note detailing is not required. This can be documented either by the primary surgeon or the assistant surgeon is the primary operative note.