As you said, my name is Hussain El-Khoussi. So I'm going to talk to you about ICD-10 and beyond, coding for success to maximize reimbursement. This may be the boring talk, so bear with me. I'll try to make it a little bit exciting if I can. So I have no financial disclosures. My committee disclosures, as you mentioned, I'm on the AAUS CCRC committee. We're a committee that meets three times a year, and we basically try to defend our codes. And I'm also an alternate advisor at the RUC. So I meet three times a year at the RUC and try to keep our codes from dropping in value. And the CCRC committee, we basically meet three times a year as well, and we answer emails perpetually about all of your coding questions. The content of my talk is my personal view and doesn't reflect the view of any of those committees. So real briefly, this is a, we'll go through an introduction to reimbursement in orthopedics and sports medicine. I'll briefly go over ICD-10 and clinic CPTs and then go to surgery CPTs. I may not tell you anything that you don't know, but hopefully I'll educate you on the process. So reimbursement is the action of payment or repayment of money that's been spent. And so in medicine, we provide a service that costs us money, infrastructure, IT, insurance, facilities, time, products, et cetera, and we get reimbursed for that. The sources of payment, we differ from other businesses in that we don't just get direct payments from patients, but we get it from a third party, which makes us a little bit different and probably a little bit of a disadvantage. So all of our revenue comes from three major sources, and this is not complete, but I have divided into basically patient care reimbursement, which is direct patient services, clinic visits, procedures, ancillary services, which others will speak about in this meeting, and then other things such as, you know, independent medical exams, medical legal consulting, real estate, et cetera. So our income is our revenue minus expenses, and we can somewhat control our revenue, but unfortunately, there's many reasons why we can't at this point. Our expenses also have been rising, and this is probably one of the reasons why many of us in this room have gone to hospital employment. A major component are the costs of maintaining a practice, EMR, IT, staff salaries, marketing, et cetera. A significant amount of that work also now is required to fight for just to get a reimbursement. So pre-certification, appeals, documentation, insurance companies essentially waste our time playing a game, trying to make us work harder to get what we deserve to get up front. So what's this talk about? I'm going to focus on the two things, clinic visits and procedures, the direct reimbursement to the provider. Again, some of the other talks today are going to focus on some of the other things that we've just briefly covered, and maybe how knowledge of ICD-10 and CPT can result in some more efficient reimbursement. And again, I may not tell you things you don't already know, but hopefully reinforce some things. So this is my education for you guys, and you may or may not know this, but how is reimbursement determined? The RBRVS system, and this was developed by CMS in 1992, and soon after, AMA developed a committee called the RUC. And the RUC is the Relative Value Scale Update Committee, and it provides recommendations to CMS about what the pricing should be based upon work. And you know that total RVUs are divided into three parts, physician work, practice expense, and malpractice expense. And so we try to fight for when we go to the RUC is basically the practice expense and the physician work part. You can look up the MPFS, the Medicare Physician Fee Schedule tool. It's online. You can go there and put in a code, and you can figure out, depending on your geographic area, what you get paid and how it's broken down into the three parts of the RVUs. Insurance companies, and I'll state this kindly, use this process as a guide. And they essentially do whatever they want, but they do use it as somewhat of a guide. So how is reimbursement determined? Well, it's determined by work. It's time, technical skill, physical effort, mental effort, psychological stress. Unfortunately for us, it's not based upon individual outcomes, not level of education or duration of education, and not on its value to the individual or society. So as technology improves, whereas you get faster or better at what you do, you're going to get paid less. That's just how the system is set up. Who makes the rules? Well, not us. CMS, NCCI. NCCI is the National Correct Coding Initiative. They're basically a part of CMS. And so they decide what you can and cannot code together and how much you get paid for. The AMA, which has the CPT and RUC, which basically tries to maintain some values, but again, the AMA fights for all physicians, and orthopedic surgeons are not at the top of their list, again, stated kindly. And then insurance companies, they also make rules that sometimes we don't have any recourse against. So how can orthopedic surgeons impact those rules? Well, they can participate in the RUC, give them feedback on time, physical effort, mental effort, and psychological stress. We can publish things that help support what we do. And unfortunately, lately, that's not been the case. We've had several publications that have come out that have disproven some value, and that actually hurts us. And so, again, I'm not telling you not to publish, but just think twice if you want to continue to be an orthopedic surgeon, what you publish and how much impacts our reimbursement. AAS global services data, that's what the CCRC committee, we basically give our recommendations for how we think coding should be done. And again, it's our opinion. So orthopedic reimbursement trend over the past 10 years, it's decreasing. We all know that. Orthopedics has been a target due to its high cost to CMS. It also doesn't help when you read publications that say orthopedic surgeons are among the highest paid. CMS tries to spread the wealth, and so it's trying to redistribute wealth. Some factors are in our control. Some are not. Most of the major reductions, unfortunately, are not in your control, and I'm going to try to focus on the few factors that are in your control. Some of those general factors that we're trying to increase, you know, CMS is trying to increase primary care reimbursement and reduce procedure-based reimbursement. This is an example of this is in the E&M code change for this year. Some of you may think, well, that's great. We get paid more for seeing patients in clinic. However, that wasn't applied to your global codes, and so all the E&M values of your global codes are still the old values. So you do not get a raise in your global codes, and you will not. We already had a couple codes pass through the RUC, and the new values were not applied to those codes. So we are, and the reason for this, if you, and again, this is not a secret, it's actually in the final rule that CMS specifically says we do not believe that the work that is in those codes is actually done. They're basically saying you are not being truthful, and you do not actually see the patient as long as you say you're seeing them. So we're not going to pay you for it. Episode bundles, you know, initially it was to increase our reimbursement. That worked well for the short term, but it was a race to the bottom, and so now CMS knows how efficient we can be, and so now we've set a new price as to how much we're going to make for certain things. The conversion factor, 2021, is 34.89. I'll show you in the next slide here briefly, but that's pretty much the lowest it's been since 1998. Payments are even lower due to things that you don't see on your bottom line, like sequestration. You still get 2% taken off every time that you get money from CMS, and it doesn't really show up to you on your bottom line. It's kind of taken out before or after, but you think you get paid $500. You get paid $490. You can look at some of the sequestration information at this link, and again, this is all more pronounced with inflation. I think there's been several publications lately that have come out in a journal that basically show that if you count inflation, we're way down over the course of time, and again, this is a busy slide. I just want you to look at 1998. It was, you know, over 36, and now we're down to 34, so, you know, we're making much less of the conversion factor. So what are the factors decreasing sports medicine reimbursement? Things that are not under our control. Typical common codes have had the reimbursement reduced, 29880, 29881, for example. Many codes are now bundled, 29877. You can almost never use. Payers take any opportunity to avoid paying. That's, again, the preauthorization issue, and they can make internal rules saying certain procedures are experimental, like currently BCBS Blue Cross Blue Shield says that 29826 is experimental and should never be used. What's in our control? Correct ICD-10 coding, correct CPT coding and understanding the bundling rules. If you don't do this, then it gives them an excuse not to pay you, so if you do it correctly, then at least you'll get paid without too much to do, hopefully. Documentation, and I'll go over that briefly as well, and then input comorbidities as structured data if you can. Tools for reimbursement, AOS Codex, or a similar tool. The CCRC committee, we basically put together codex and work with KZA to do that. MPFS, you can basically look at what you would get paid for certain codes, and then Karen's UpCode. They're a very, very good source. They actually come to our CCRC meetings, and this is not a plug for them, but they're very knowledgeable. Some general tips. The diagnosis, I mean, this is very basic stuff. I'm sure you all know it, but you'd be surprised how many times I'll see my partners coding in the EMR chart, and they don't do this. So always choose a right or left designation. You won't get paid if you don't do that. It's a nice excuse not to pay you, and again, you think it's really foolish not to, but they just don't, and maybe it's because their physician doesn't code. Maybe they let their staff code, and their staff doesn't know any better, so maybe their physician should look back and see. Generally, EMR or other sources can help you do this. You know, when I want to code something, I'll put down meniscus left knee initial, and those three words are enough to pop up the codes that I need, and you just click right or left. I mean, so that's easy. Input the diagnosis that impact your treatment. Diabetes, history of DVT, those things can help you, especially with the current E&M changes. Those comorbidities can help you use a higher level of coding. Again, this is really simple. So that bottom one's there academically. It should never be used. You should only use something that has a right or left designation. So this is the code for rotator cuff tear. Comorbidities, I've just listed a few here for your handout that you can sort of look through and consider using these if they apply to your patients. Some personal tips. You know, if there's no injury or unsure of the diagnosis, I just use the joint pain code. It's an M code. If there's any trauma or injury of any sort, I'll use an injury code. Okay, so their patient was injured, I'll use an injury code. I will not use a joint pain code for this, and this makes a difference for workers' comp, for example. If you use an M code for workers' comp, you won't get paid. So if you put down, you know, chondromalacia, M94.261, you're not gonna get paid for your workers' comp case or they'll give you a hard time. You have to put down a knee sprain code. So there's one called S43.491. I think it's a general knee sprain code. If you put that down, it'll be easier for you. And then imaging, if it confirms the diagnosis, I'll use the specific code. So here I have this, you know, slide which summarizes a few things. But basically, again, if a patient comes, they're new to clinic, no trauma, several potential diagnoses, imaging's not definitive, I'll use a joint pain code. Okay, that's an easy one to use. But if they come in, you know, a 25-year-old and they slipped and fell and their knee's swollen and the diagnosis could be anything, ACL, patellar dislocation, I'll just put down a joint sprain code because it's a new injury. And then if they come in and I'm pretty convinced of the diagnosis, you know, playing soccer, valgus load, non-contact, heard a pop, two plus lock went on exam, even though I don't have imaging or an MRI that proves it, I'll put down an ACL tear. Okay, so you have to have your level of certainty and the highest level of certainty is what you should use. So new versus established patients, this is pretty simple and straightforward, but just for you to know, if a patient has not been seen by the practice within three years, he's a new patient to you. So if I saw a patient five years ago and they come back to see me, they're a new patient. Okay, so you can code a new patient code. It does make a difference for how much you get paid. And again, different subspecialties. So if you have hand surgeons or primary care sports in your clinic and they've seen a patient within three years, you can still code it as a new patient code. Okay, so again, it makes a difference. Very busy slide. This is just the, I'm not gonna go over this, but this is just the new E&Ms and this is some guidance. This is published by the AMA to give you some guidance on how to use them. I've kind of tried to boil it down into this slide right here. So the bottom line is you should use the medically appropriate history and exam. You don't have to put down, you know, all this long heart stuff anymore or ENT. Basically, you put down what's appropriate because it's not gonna help you in terms of your coding level. What's gonna help you is the bottom slide there. So list all the problems. And so if they have a meniscus tear, an ACL tear, an MCL sprain, list all the problems. Describe the complexity of those problems. So number and complexity of problems is number one. Number two, summarize the data that was reviewed and analyzed. So if they come in and they have had prior surgery and they have scope photos you looked at, well, dictate that. You looked at the scope photos, what did you see? They had an MRI they brought with them. Dictate good resolution, poor resolution, where it was done, technique if you want to, what you saw with the official report. So all that is information that adds to your complexity. And then ultimately, you review the management risk options. So for example, if they come in and it's just a straightforward 14-year-old kid with an ACL tear whose growth plates are closed, that might be straightforward. But if it's a nine-year-old's growth plates are open, I mean, that's more extensive discussion. That's higher complexity. There's more comorbidity there. And so you should add that to your complexity of your coding. So these are just general scenarios. Level two, somebody comes in with a skin abrasion. That's a level two for me. They come in with a nonsurgical knee or shoulder injury. So for example, if I think they had a grade one MCL sprain, they're gonna get better. That's a level three or four. And I kind of give us some wiggle room there because it depends. There may be other factors here that may make it a level four. And then finally, the rotator cuff or ACL tear. I mean, generally, if you're gonna go for a procedure of some sort or scheduled procedure of some sort, you can justify a level four. And then again, if it's, for example, if some of you do total shoulders or rotator cuffs and the patient has diabetes, hypertension, history of stroke, history of DVT, well, those are the comorbidities that would bump you up to a higher level. Same thing follows for established patients. So same kind of scenario. So there's no one diagnosis that you would stick in one E&M coding type. Okay, so that's the important thing here. There's some wiggle room depending on other factors. Modifier 25, I'll briefly mention. It's really important. If you have a patient who you're gonna do a procedure on, and for us, it counts for injections, for example, in clinic. If you have seen them for the first visit and you give them an injection, use a modifier 25 if you wanna get paid for the injection code. If it's an established patient, they come in, you were not intending on giving the injection, but after a discussion, you gave one. Again, modifier 25. If it's a patient that you saw in clinic and they said, well, I want my injection in three weeks before I go on vacation, and they come back for that injection, don't do an E&M. Okay, just you go to code for the injection. All right, same thing for some of these HA injections. If you know they're gonna come back in three weeks for their first injection, you shouldn't code an E&M with that. Modifier 24, an example is you do an ACL reconstruction and then within three months, they complain of shoulder pain. You examine them for the shoulder, you can put a modifier 24 on that, and then you can code for the examination of their shoulder. So this is just to kind of give you a little bit of example. So 298.0, 298.1, they're our main codes that we've used in knee surgery, at least, and you can see that they dropped after 2011 significantly, and again, that's CMS wanting to control costs, and so they dropped the value of those codes, and so they're the lowest ever. Next is 298.77. You might say, well, look, we got a bump in 298.77. Well, if you look at bundling, and I'll show you that in a second, you really can almost never use 298.77. So if you do a 298.81 or 298.0, then it excludes the ability to use a 298.77. So, you know, compared to 2010, for example, you know, that's a significant reduction in what you get paid for those procedures. 298.26, you know, it was 9.16, but there's always a second or third code, right, and so it was always subject to the multiple procedure reduction rule, so you might have gotten paid, you know, 4.6-ish, you know, as a general rule, or if it was a third code, even less, and so we thought it wasn't a huge drop, but, you know, it's down to a three now, and now insurers like Brookclaws and Bushield are saying they're not going to pay for it no matter when you do it. Other codes there, 292.2, 292.3, we just had them reviewed in 2020. You can see there was a drop there, and actually, we were happy about that minor drop, and so small victories. So just some common E codes, 298.77, again, I already said, you can almost never use it alone, so you can use it by its... I mean, not alone. You can almost never use it with other codes. It has to be used almost alone, so it is paid more, but it's not used as often, and CMS knew that. 298.79, it can be used with other codes, but not with 298.77. 298.75 can only be used alone, so you do apply co-excision. You do anything else, you can't code for that 298.75. Okay, so you do a brazen chondroplasty of the trochlea, and you do apply co-excision, it's just a 298.77. Okay, you do a partial medial meniscectomy and apply co-excision, it's just 298.81. 298.76 can be used, but you have to do it in two compartments, and so by definition, if they ever see you use 298.80 and 298.76 together, it gets denied because you only have three compartments. There's going to be one compartment overlap no matter what you do according to them, so you have to be careful with that as well. 298.26, already mentioned, it's only an add-on code, poor reimbursement anyway. Blue Cross Blue Shield is now denying. We're actually in the process right now of trying to write appeal letters to them, but again, this is a private insurance company who can do what they want, and so we're trying to show them the data. Again, I made an allusion earlier. This doesn't help. There have been a lot of publications saying it's not helpful, and so when those publications come out, they grab onto those, and they cherry-pick which articles support their view, and then we're not going to get paid for it. 298.23, again, it can be used with four codes, and that's published by the NCCI, and those are the four codes that we're used with, and again, you have to read at least three structures. We define this code, my committee and myself, we define this code very specifically giving you specific structures that are not all-inclusive that you can count as specific structures, and these were accepted by CMS and the RUC, and so when you look through those structures, it's glenoid, articular cartilage, humeral articular cartilage, glenoid labrum. You know, superior labrum is different than anterior labrum, so you can get points for different structures and code this. 298.22, again, can almost never be used because you can't use it with anything else. It can only be used with 298.26. So, again, you guys probably know all this, but if there's one thing, I'll just give you a reminder. Make the operative note standalone. It needs to be a standalone document. Okay, so what I mean by that is put your ICD-10 in there, correlate it with your CPT, put the details of the history that justify how you made the diagnosis, the fact that they failed conservative treatment, and why you're there that day doing surgery, okay? If you have an assistant, put some language as to why the assistant was helpful, okay? If you want to do a modifier 22, make a separate section. This is why it's a modifier 22, and I'll tell you, you got to add things like complexity of case, took longer. I wouldn't say a time. I wouldn't say it took me 20 minutes longer, but I would say this took me 25% more time than it would have taken me for a standard rotator cuff repair. That's the kind of language they're going to look for, okay? And then, so all this stuff, it may take you two to five minutes extra. You may build a template, but if you put it in there, it will help reduce these denials that you get, okay? So just, even with that, you know, I had a contractor from Medicare just two weeks ago deny an assistant for a massive rotator cuff tear that I did, and I had the language in there. And I just had to write more language, and it's not clear why they do that. They just want to waste your time and make you fight for every little penny. So orthopedics has been targeted to decrease reimbursement. This is going to continue unless we work together to provide evidence of our value and our work. Try to match right and lefts. Understand bundling and use of modifiers, and really focus on thorough and pertinent documentation. It takes you a few more minutes up front, but it'll be worth it on the back end. Thanks.

reimbursement

orthopedics

ICD-10 codes

CPT codes

insurance companies

fair reimbursement