I'm honored to be here, ICD-10 and Beyond, Coding for Success to Maximize Reimbursement is the title of the talk. I could go deep into the weeds and this could take us a couple of hours, so I'm going to speed through and just kind of give you some highlights and we can certainly touch on things afterwards. These are my disclosures. Most important ones. I'm on the AAOS CCRC Committee, which is a committee that reviews all of our coding and tries to help us set some standards. And also through that, I'm also the RUC alternate advisor, so I'm one of the two people who sits at the RUC who tries to help us defend the value of our codes. This does not reflect the view of any of those committees. So I'm going to go through an introduction on reimbursement in orthopedics as a general concept, move to ICD-10, move to clinic CPT, and then move to surgery CPT, and again, I'm not going to go into the weeds. I'm going to give you some generalities and we can hit some things later if you need to. So reimbursement is the action of payment or repayment of money that's been spent. For us in medicine, we provide a service, costs us a lot of money, staff, infrastructure, IT, insurance, et cetera. Reimbursement is receiving money to cover those expenses and we get those from both patients and third-party payers. The unique thing for us in medicine is the third-party payer part. So revenue is, there's three different general ways a orthopedic surgeon can generate revenue. I'm going to focus on this first one, which is provider direct services, which are clinic visits and procedures. You'll hear about the others from the other talks later today. I personally think this is key. This is your intrinsic value as a surgeon. This is what you trained for. This is the knowledge in your head. This is the value that you have if you were in the middle of, if you're in Africa, for example. It's other things or things that can generate revenue here in the United States. So income is revenue minus expenses. Expenses are a major component. Cost of maintaining a practice has increased significantly. I've been in practice for 20 years now and it just keeps going up and up. Currently there's a significant amount of work that's now required just to receive that reimbursement. So it's not just from your infrastructure, but it's also we have to hire staff and third-parties to pre-certify, get appeals, and help us with documentation. So this talk is about reimbursement from provider direct services, clinic visits and procedures, how knowledge of ICD-10 and CPT can result in a potentially more efficient reimbursement. So how is reimbursement determined in orthopedics? The RBRVS system, it was established in 1992. I won't go into the details, but you understand there's total RVUs, it's divided into three different parts. You can always review the current reimbursement RVUs online through the MPFS, which is on the CMS site. Insurance companies use this process as a guide, but honestly they do whatever they wish. How is reimbursement determined? Work. And so at the RUC they define work by time, technical skill. It is not individual outcomes, it's not level of education, and it's not the value to individuals or society. So this is outside the realm of capitalism. Who makes the rules? CMS, NCCI, the government, the AMA helps to try to fashion those rules, and then insurance companies make their own rules. How can orthopedic surgeons impact the rules? We'll participate in the RUC, and that's what I try to do. Research and publications to prove our value, and then AOS global services data, the CCRC committee puts together a general set of guidelines on what we think is appropriate coding. Orthopedic reimbursement over the past 10 years has decreased. Fee-for-service is decreasing per procedure. Orthopedics has been a target, and because we're high value and high utilization, some factors are in our control, but most of them are not. So one example is the E&M coding system, 2021 it changed. You get increased reimbursement for your E&M codes, which helps us when we're in clinic, but we were specifically excluded from that in the 90-day global period, so we effectively took a cut. There are episode bundles, for example, BPCI, things that were very common several years ago, which have sort of diminished a little bit. The goal there was to increase provider reimbursement in the short term, but in the long term, it's decreased our reimbursement. And then other things like the conversion factor, the current conversion factor proposal for 2023 is to reduce it by $1.50, I think, which is a 4.4% reduction. In addition, there are other things that we don't really have a tangible hold of, which is things like pay-as-you-go, which is a 4% cut, and sequestration, which is a 2% cut. So there are a lot of cuts in Medicare payments that we don't really see, but we will feel it in our pocketbook. You can always go to the CMS site and review some of this information. And again, there's been a couple of complications which have come out, which have shown that if you consider inflation, our reimbursement has diminished even further. This is just a table that I had from last year. You can see there the conversion factor. If you look back at 1998, for example, it was higher in 1998 than it is in 2022, and it's going to be even lower in 2023. So factors for decreased reimbursement in orthopedics that are not in our control, typical or common codes have had their reimbursement reduced. I'll go over that in a few minutes. Many codes are now bundled. Payers take any opportunity to avoid paying with preauthorization, calling some of our procedures experimental. And then they use the most restrictive rules nowadays, which is a recent trend. They use NCCI rules, which are the most restrictive. It's in our control, not much, but correct ICD coding, which is what I'm going to mention today, correct CPT coding and understanding the bundling rules. If you don't do these things, you're going to waste your staff's time trying to resubmit for coding and billing. Documentation is key, of course, and then inputting comorbidities and structured data. Some of your tools for reimbursement, Codex, MPFS, Cairns Upco courses are excellent. They are sort of a conduit for the CCRC committee, and they sort of reflect our opinions. Some general tips for ICD-10, always choose a diagnosis, the right or left. I know this is very simple, but sometimes, even myself, when I do it on the EMR, it won't give me a seven-digit code. You have to check yourself and make sure you get a seven-digit code, not a five-digit code that designates right versus left. EMR can help, as I mentioned, but sometimes it doesn't go all the way. Input the diagnoses that are comorbidities that can also help you justify a higher level of reimbursement or higher coding for E&Ms. So as one general example, you know, rotator cuff right and left has to be a seven-digit code. If you input the last one, you're not going to get paid, and the insurance company will be very happy because they can delay your payment as long as they wish. Comorbidities, you can get this from my slides. These are just general ones you can put in your back pocket. They're very common ones, orthopedics, that you can sort of add if the patient has it and you think it impacts their treatment. Some personal tips, I'll go over this in the next slide, but somebody comes in, they have no injury, I'm unsure of the diagnosis. I generally use a joint pain code initially. It's very simple. If they have a trauma or injury, I'll use a joint sprain code, and if I think they have a specific diagnosis, even if it's based just on examination, I'll give them a specific code. So as an example, you know, a patient's on the right there in yellow at the top, their new clinic, no trauma, several potential diagnoses, have images that are not definitive, I'll just call it a pain code, whether it's right, left, shoulder, or knee for me. Second situation, you know, 18-year-old kid, gets valgus load to the knee, might be patellar dislocation, might be an ACL tear, I'm not sure which. I'll give them just a joint sprain code initially and change it later, and if they come in and it's a very classic history and exam, they have a positive Lachman, then I'll give them the ACL code. So everything just depends on how sure you are of the diagnosis. If you're not sure, go with the less discrete code. Of course, new versus established, I think most of you may know this, but if a patient has not been seen by you in three years, even if you saw them four years ago, they're still a new patient to you. If they've been seen by your practice by a different subspecialty, though, they're still a new patient to you. You can code as a new patient for those patients. Very busy slide. You can look at this from the CPT book. This is the new criteria for the E&M coding. And I'm just going to show you a couple snippets from that book that sort of give you a little bit of a general concept of what you need to think about. So the first one is, the first three components here, history examination and medical decision making, those are the three main things you need to focus on in your E&M in order to get paid. The other three main things we're looking at is medical decision making or time. And we normally would use medical decision making in orthopedics. Again, if you want to use total time, it now includes not just face-to-face time, but non-face-to-face time. So that's important. So if you're spending time in a clinic looking at an EMR, looking at some images they brought in, that all adds up. And so if you think you spend more time and you can't code higher with the MDM, then you can use time for those. Again, this is just reinforcing that, MDM or total time, the date of encounter. For MDM, things that we think about, number and complexity of problems. So if you see them for three joints for three different issues, that's obviously a higher complexity, amount and complexity of data that you review. So if a patient brings in an operative report from somebody else, if they bring in arthroscopic photos, if they bring in an MRI, I mean, obviously, it's more data that you have to review and that can increase your coding. And then the risk of complications. So for example, an ACL tear in an 18-year-old has some complications, but a total shoulder replacement in an 80-year-old with diabetes, hypertension, and a history of heart attack, that would be obviously a higher risk of morbidity. And so you can always use those factors to evaluate how high you want to code. Generally in sports medicine, we will code low and moderate severity. Occasionally, we'll get to high severity. So for example, a knee dislocation, that would be a higher severity or sometimes some fractures. But we're usually going to be in the low to moderate severity, which is going to be level three and level fours. This is one snippet I've included. I can come back to this later, but this is a difference in private practice and institutional-based surgeons. In private practice, you take a little bit of a hit. If you order an X-ray on somebody when you're in clinic, you don't get to consider that one factor for ordering a test or for medical decision making. If you're in work for an institution and you order it and the radiologist reads it, then you can use it. It's an interesting little thing that the AMA has added that impacts private versus non-private surgeons. So documentation, medically appropriate history, medically appropriate exam, and imaging, those are the things you need to focus on. You don't have to put all the other stuff that you used to put in there, review systems, all that is frivolous. Medical decision making, so list all the problems, describe the complexity of the problems, summarize the data that you reviewed and analyzed very specifically, and then review the types and risks of management options that will help you be able to justify your coding. So again, I'll go through this really quickly. So level two, new or established, and if somebody comes in with a skin abrasion, that's a level two. You look at it, you say it's not infected, you say, come back and see me in two weeks, make sure it's healed and you're done. That's a level two. Level three or four on either one, I'd call this an MCL sprain, for example, for the knee or a rotator cuff sprain for the shoulder. It's non-surgical generally, but it's something that has to be managed. You can't just say you're good to go, come back and see me, do some physical therapy, rehabilitation. And that can be a level three or four depending on the scenario of the patient. And then things that are generally surgical, I will generally use a level three or four depending. I'll very rarely get to level five myself unless there's a specific reason that the patient is an outlier. Common modifiers, really quick, modifier 22. We generally use that for injections in clinics. So for example, if somebody comes in, they're a new patient for you, you evaluate them, decide they need an injection, put a modifier 22, I'm sorry, 25 on your E&M and then you can code for the injection. If they come back to clinic as an established patient and you have a discussion and then decide at that clinic visit you want to give an injection, you can use a modifier 25 on the E&M. However, if you saw them in clinic and your last note in your clinic note said they will return for an injection in two weeks, you should not bill for the injection on that return to clinic visit. You cannot use a modifier 25. Modifier 24 is used if you see them for a different problem in the global period. So for example, if I do a rotator cuff repair on somebody and then three weeks later they slip and fall and hurt their knee, I can code for their knee in evaluation with an E&M and add a modifier 24. So some common knee and shoulder trends. Just to give you an example, our bread and butter codes have been 29880 and 29881 for the knee. Their highest values were in 2010. Their current values were the lowest they've ever been. And that's probably where they're going to stay. Additionally, 29877, you see the value has actually increased. Well, that's not all that useful because you can very rarely use 29877. You can only use it by itself essentially and very, very rarely is that done in practice. 29826 used to be a standalone code and then it got switched to an add-on code. And so currently it's worth three RVUs no matter when you use it. So for some common knee codes, I'm giving you some notes here and again you can refer to the handout. But 29877 can never be used with any other code. It's incorporated in 29881, 29880, and 29879. So it has to be used alone. 29879 can be used with all other codes but not with 29877. 29875 is a standalone code. So if you do a meniscectomy and then debride a placa, you cannot code 29875. 29876 is used for debriding two different compartments. And so by definition, you can't use it with 29880 because you'll have to overlap with one compartment since there are only three compartments in the knee. 29826, as I mentioned, is a add-on code only. It's called a ZZZ code. It's worth three RVUs currently as of a couple of years ago and still some insurance companies are denying it. We've had some calls with Blue Cross Blue Shield and they're pretty adamant. So I don't know if we're going to be able to fight that battle. But that's something that some insurance companies are starting to deny. 29823 just came up for code revision a couple of years ago and currently it can be used with four other codes, although there is some discussion as to why it can still only be used with four other codes. It should be able to be used with any code that you want to use it with as long as the three structures you debride do not overlap with the fourth structure that you address surgically. 29822 can only be used alone, so it's similar to 29875 for the knees. You can never use it with anything else except as a base code for 29826 because 29826 cannot be used primarily. It has to be an add-on code. Operative reports, these should be standalone documents. This will help you immensely. For example, when I dictate an operative report, I always dictate the ICD-10 code and I match it up with the CPT code. I give the details of the history that justify the procedure. I give the details of the case that justify each ICD-10 code and each CPT code. I explain very specifically how an assistant was needed, not just he or she was very helpful. I specifically say what they did. They retracted the perineal nerve. They did this. I mean, whatever they might have done, I'd say what they did. And then you have to say why modifier 22 is used if you want to use that. So you have to say, well, this took me 25% more time than the average case because, and then you have to give reasons. So orthopedics isn't targeted to decrease reimbursement. This will continue unless we work together to provide evidence of our value and work and strive to retain the value of our work. You can maximize patient care reimbursement by matching right and left for ICD-10 codes, understanding the new E&M rules, understand bundling and use of modifiers, and focusing on thorough and permanent documentation. Again, I'm sorry we went through this so quickly, but this is a vast topic and it can't be covered in just 15 minutes. Thank you.

ICD-10 coding

reimbursement in orthopedics

CPT codes

revenue generation

insurance reimbursement