There are three key components of medical coding: patient history, physical examination, and medical decision-making. With these components in mind, we developed a simple five-step guide to orthopaedic coding that will help to reduce the amount of claims errors, payment denials, and time spent waiting for corrections to be accepted.

Step 1: Determine If They Are A New Patient

Determining whether a patient is considered “new” or “established” depends on same-practice and same-specialty rules.

Same-practice refers to two or more physicians within the same group, regardless of where each physician works individually. Physicians in a multispecialty practice who are in the same specialized area are considered same-specialty.

If a patient has seen at least one physician in the same specialty, at the same practice, within the past three years they are considered an “established” patient. Otherwise, they are considered a new patient.

For example, if a patient has seen someone a foot and ankle specialist, then goes to see a hip and knee specialist in the same practice, they are still considered a new patient at the time of their appointment with the hip and knee specialist.

This three-year rule still applies, even if a patient changes insurance providers within that period.

Step 2: Review Patient History

A patient’s history consists of the following sections: 

  • Chief complaint (CC)
  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family, and social history (PFSH)

Chief Complaint 

The patient (or patient’s parent or guardian) usually states their chief complaint(s) in their own words. 

History of Present Illness

The HPI section uses descriptive elements to document the development of the patient’s current problem(s), from the first sign/symptom or from the previous encounter to the present appointment. HPI elements include:

  • Location (e.g. left arm)
  • Quality (e.g. sensation of aching, burning, radiating pain)
  • Severity (e.g. on a scale of 1-10)
  • Duration (e.g. “problem started two weeks ago”)
  • Timing (e.g. constant or on and off)
  • Context (e.g. lifted large object on the job)
  • Modifying factors (e.g. better when heat is applied or soaked in hot water)
  • Associated signs and symptoms (e.g. tingling in fingers)

Depending on the patient’s insurance plan, the HPI may need to be documented by the physician who is sending the insurance claim. If a patient is on Medicare, physicians must document that they have reviewed the patient’s history and verify whether the history was taken by assisting staff or from a patient portal questionnaire.

Review of Systems

ROS is an inventory of body systems. This inventory is obtained by asking a series of descriptive questions to identify signs or symptoms related to what the patient may be experiencing. The Center for Medicare and Medicaid Services (CMS) recognizes 14 systems.

Past, Family, and Social History

PFSH includes a review in three areas:

  1. Past History: The patient’s past illnesses, operations, injuries, medications, allergies, and/or medical treatments
  2. Family History: A review of the patient’s family and their previous medical events, especially diseases or conditions that may be hereditary, or may place the patient at risk for disease or treatment complications
  3. Social History: An age-appropriate review of past and current activities, such as jobs, marital status, exercise level, etc.

At the outpatient service level for an established patient, you need to document at least one specific item from two of these three areas for a complete PFSH. However, for new patients, you need to document at least one specific item from all three of the history areas.

Assisting staff or the patient (or patient’s parent or guardian) may document the information related to PFSH, as long as the physician includes notation supplementing or confirming this information.

Additional Considerations

The amount of history that needs to be taken to get the correct coding level depends on whether a patient is considered new or established. For example, if an established patient has no changes in symptoms or history then the physician can note that there are no changes, as long as the physician references the date of the last ROS and PFSH and report that they have reviewed the patient’s current and prior history, and found no changes in their conditions or history.

Step 3: Review Physical Examination

A musculoskeletal single-specialty evaluation includes general exam elements and the six musculoskeletal areas: neck, back, right and left upper extremities, and right and left lower extremities. For each musculoskeletal system, there are five exam components:

  1. Inspection/palpation: Note any misalignment, asymmetry, crepitation, osseous deformity, defects, tenderness, effusions
  2. Range of motion: Note pain, crepitation or contracture, and active and passive limits
  3. Stability: Note laxity, subluxation/dislocation
  4. Muscle strength and tone (documented on a scale from 0-5, with zero being complete lack of strength and tone, and five being full strength): Note atrophy, abnormal movements, flaccid, cogwheel, spastic, etc.
  5. Skin: Note scars, lacerations, ecchymosis, rashes, lesions, cafe-au-lait spots, ulcers, etc.

To properly code a comprehensive physical examination you’ll need documentation of each of the first four exam components, and assessment of the skin in 4-6 body areas. A comprehensive exam also includes evaluation of at least four out of seven vital signs, the lymphatic system, and a review of the neurological/psychological system.

There must be a medically necessary reason for a physician to perform an examination on a body part outside of the chief complaint. 

Step 4: Review Medical Decision-Making (MDM)

MDM relates to how complex establishing a diagnosis and/or management plan will be. There are three elements that determine the type of complexity:

  1. Number of diagnoses or management options (minimal, limited, multiple, or extensive)– Must be documented with every patient encounter
  2. Amount and/or complexity of data to be reviewed (minimal or none, limited, multiple, or extensive)– Should include documentation about tests to be ordered, records to be pulled and re-examined, and consultations with other treatment providers, among other things.
  3. Risk of significant complications, morbidity, and/or mortality (minimal, low, moderate, high)– Based on the risk anticipated between the current patient encounter and the next one, and includes risk associated with diagnostic procedures and/or management options

There are four types of medical decision-making: straightforward, low complexity, moderate complexity, and high complexity. To qualify for a certain type (and produce the right orthopaedic coding), at least two of the three elements must be met or exceeded.

For example, a patient may have a limited number of diagnoses, and there is a limited amount of data to be reviewed in relation to making or managing a diagnosis, but a minimal risk of complication. The type of complexity would be considered low complexity, as opposed to straightforward.

Step 5: Apply The Appropriate Code

For a new patient, each of the three key components (history, examination, and MDM) must be at or above a specific coding level for it to be applied. However, for established patients, only two of the three key components need to meet or exceed a certain coding level for it to apply.

For example, if an established patient has a moderate level of complexity, a low/limited number of diagnoses, and a moderate level of risk, then MDM the code you would choose would relate to a moderate component.

Consider Time

If most (over 50%) of encounters with the patient and/or their family involve counseling or coordination of care (e.g. counseling on how to manage pain), then it’s important to document the total amount of time spent before, during, and after the encounter on patient care. The amount of time corresponds to a certain code.

Streamline Your Orthopaedic Coding Efforts

There are many components involved in getting the correct orthopaedic coding: a completed patient history, either gathered by the patient or an assisted staff; the physician, who has to sign off on everything; a previous physician (if applicable), who current caretakers have to contact in order to pull previous records and histories; and the person inputting the medical coding to send out claims.

Keeping up with training, changing policies, and the requirements to ensure the correct coding language is in place is crucial to patient care and your bottom line but undeniably tedious. That’s why many practices are streamlining their efforts with an all-in-one DME coding, insurance billing, documentation review, and denied claims management solution.

That’s where Select Ortho comes in. Our easy-to-use DME billing and revenue cycle management software and highly qualified DME experts have helped practices large and small reduce errors and increase their collection rates.

By partnering with Select Ortho, you and your staff can stop worrying about whether you’ve got the right orthopaedic coding, the efficiency of your process, or getting denied for claims, and instead focus on what you do best: providing the highest quality care to your patients.

STREAMLINE ORTHOPAEDIC CODING