Complexity
A patient presents to clinic after an injury during a flag football game. They are diagnosed with a displaced fracture of acromial process of the left scapula.
How would you answer the following question: "Did the provider address an extensive acute injury? If so, make sure the diagnosis is included in the note. "
Yes!
Extensive acute injuries include:
A patient comes in one week before their surgery is scheduled to ask questions and complete paperwork regarding surgery. How would we bill this visit?
This would be a pre-op patient. This visit is included in the surgical package and is not separately billable.
The 48 hour rule no longer applies.
A post-op patient gets an injection post right knee meniscus repair to help treat his arthritis that has been flaring up since his surgery. How would we code for this?
mod 24, 25, and all appropriate injection codes
A patient comes in for a follow up on a nondisplaced bimalleolar fracture of left ankle. How would you answer the following question: Did the provider address an extensive acute injury?
Yes!
ALL fractures are now considered extensive acute injuries.
A patient comes in as a WC case. They slipped and fell down the stairs at work a week ago, injuring their right ankle. The provider orders an MRI to evaluate for tendon damage. What diagnosis codes would you use?
W10.8XXA Fall (on) (from) other stairs and steps, initial encounter
Y99.0 Accident at workplace
M25.571 Acute right ankle pain
We should include the mechanisms of injury/external cause codes for WC cases.
A patient presents to clinic after falling on their left shoulder two days ago. The provider dictates that on the patient's x-rays, they have significant glenohumeral joint arthritis. The provider orders an MRI of the left shoulder to evaluate for a rotator cuff tear. What diagnosis codes would you use?
M19.012 Primary osteoarthritis, left shoulder
M25.512 Acute pain of left shoulder
What classifies a procedure only visit?
For a visit to be procedure only, the procedure must be pre-planned OR they have received this injection for the same condition in the past. Additionally, no other significant E/M is performed - https://docs.google.com/document/d/1Z4MW-qsrKQ9Sq7L3ZJbzxQ5jMEXkGuLampMrVx4ump4/edit
A patient comes in within the global period to have a cast change. How would we code for this?
add mod 25 and CPT for casting procedure
Since this is not his first casting, it can be billed for separately. The first casting will be bundled with surgery.
Mod 25 will not populate in Assist at this time and must be manually added to the Superbill.
One year ago, a patient hit their finger with a hammer. They sustained a closed displaced fracture of the proximal phalanx of right index finger. They come in to clinic today with right index finger pain. The doctor attributes this to malunion of the fracture. What code would you use?
S62.610P
When coding for resolved traumatic fractures you would use the fracture code with a "D" ending, but in this case, you would use "P" for malunion.
A patient comes in for a follow up on the left knee. They have complex tear of the medial meniscus, but they do not wish to have surgery at this time. They receive a cortisone injection at today's visit. How would you code for the diagnosis?
S83.232A
Complex tear of the medial meniscus, current, left knee, initial encounter.
The injection counts as active treatment, so we would use the seventh character code A.
What is the difference between tendinosis and tendinitis?
Tendinosis is a degenerative condition that will worsen over time. It is considered chronic.
Tendinitis is an acute condition with treatment and is only considered chronic if the symptoms last longer than 12 weeks.
A patient presents to the clinic with a right ring finger trigger finger. They report that they their symptoms began approximately 8 months ago.
How would you answer the question: "Is the patient being seen for a chronic or acute condition? See the tooltip for definition of these condition types."
Acute
To be considered chronic, the trigger finger must be recurrent or have lasted for over 1 year.
A patient has surgery for acquired hallux valgus of the right foot. They come in four months after surgery for a follow up. Their pain is resolving. What code(s) do you use?
Encounter for other orthopedic aftercare
Z47.89
(If their pain was completely resolved, we would code Z09 + history of the condition)
A patient comes in for a follow up on the left foot following a stress fracture. The doctor notes that the fracture is completely healed at their visit. What code(s) would you use?
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z09
Personal history of (healed) stress fracture
Z87.312
These two codes will be used for resolved non-traumatic stress fractures.
A young boy and his mother come in for a follow up on his right ankle. He has a high ankle sprain and was casted at his last appointment. He is here for a cast change because his cast got dirty. How would you code for the diagnosis?
S93.491D
Sprain of other ligament of the right ankle, subsequent encounter.
The A code does not need to be used in this scenario because the boy is routinely healing and the change is only made for more hygienic purposes.
A patient returns for an Xiaflex manipulation. How would you answer the following question? Did the provider address a recent, short-term acute illness or injury for which treatment is considered?
Xiaflex injections are used to treat Dupuytren's contracture.
This question will not populate as Dupuytren's is a chronic condition.
If a patient sees Dr. Roberts on 12/16/2022 and then comes in to see Dr. Rogers today (12/22/2022) and they have BCBS insurance, will they be considered established or a new patient?
Established
Rogers' specialty code is now 20, Roberts' is 23, but BCBS does not accept sports medicine as a primary specialty, so if a patient has BCBS in this scenario, they would be considered established.
A patient sustained a bucket-handle tear of the medial meniscus of the right knee 9 months ago. They had surgery 5 months ago and they present for a follow up. What code(s) do you use?
Bucket-handle tear of medial meniscus of right knee as current injury, subsequent encounter
S83.211D
For seventh character codes, you will use only the 7th character code and change A to D. You will not use encounter for other orthopedic aftercare.
A patient presents for evaluation of a left hammertoe. They also have pain from a healed nontraumatic stress fracture. What would be the primary diagnosis for the visit?
Hammertoe of left foot
M20.42
If there are other main diagnoses dictated by the provider, they should be prioritized over Z09.
You would code z09+Z87.XX if the healed fracture is the only reason for visit.
The provider dictates that the patient's vertebrae has slipped backward along the intervertebral disc. What code would you use for this diagnosis?
M43.8X Other specified deforming dorsopathies
This is how we code for retrolisthesis.
This differs from spondylolisthesis where a vertebra slips and moves forward along the intervertebral disc.
A provider prescribes Diclofenac and recommends the patient begin taking NSAIDs for pain as needed. How would you answer the following question?
Did the provider manage a medication for the patient during the encounter (ex. update dosage or frequency, order a refill, prescribe a new medication, discontinue medication)?
No
Diclofenac (Voltaren gel) and NSAIDs can be bought OTC, so we would answer no this this question.
We would answer yes to the significant treatment question.
The patient presents with worsening back pain and was seen previously by Dr. Gullung, who ordered an MRI to further evaluate the soft tissue involvement. The MRI was taken at an outside facility. Today, the patient is being seen by William Recknor, who evaluates the images of the MRI and provides his own interpretation of the conditions shown.
How should ordering and independent interpretation points be awarded for these two providers?
Dr. Gullung would receive credit for ordering the MRI and Dr. Recknor would receive credit for independent interpretation because the MRI was taken at an outside facility.
"The Southeastern Imaging Group will count towards independent interpretation as long as there is no CPT code in the EMR and it meets other requirements"
A patient sustained a traumatic complete tear of the right rotator cuff and had impingement syndrome of the right shoulder. They had surgery six months ago and they come in today for a follow up. What codes would you use?
Traumatic complete tear of right rotator cuff, subsequent encounter
S46.011D
Encounter for other orthopedic aftercare
Z47.89
You would use Z47.89 for the impingement syndrome because it is a non-seventh character code and you would pull forward S46.011D with the "D" ending because it is a seventh character code.
A patient has age-related osteoporosis. The patient comes in for a follow up on a fracture of the right ankle and foot due to osteoporosis. The doctor notes that the fracture is completely healed. What code(s) would you use?
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z09
Age-related osteoporosis without current pathological fracture
M81.0
Personal history of (healed) osteoporosis fracture
Z87.310
A 65 year-old woman was a passenger in a car accident five years ago and suffered a TBI. As a result of the TBI, she has recurrent seizures. How would you code for these?
Other generalized epilepsy, not intractable, without status epilepticus
G40.409
Other specified intracranial injury without loss of consciousness, sequela
S06.890S
*A sequela is a residual or produced condition that is a result of a past illness or injury
*When coding a sequela, you will usually need two codes: one to describe the nature of the sequela and one to describe the now-healed illness or injury that led to the current condition