Editor’s note: This is the second article updating information first provided in the May 2007 edition of AAOS Now. This article covers components of the orthopaedic evaluation, while the previous article covered the issues of new and established patients and consultations.
The orthopaedic evaluation is made up of three key components: the history, the physical examination, and medical decision-making.
The history component
The history component consists of the chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and social history (PFSH) sections.
Document a CC for every visit, using the patient’s own words. If the patient states, “my back is killing me” for the first visit CC, “follow-up for low back pain” might be the CC for a follow-up visit.
The HPI uses descriptive elements to document the current problem. This section of the history must be obtained and described by the billing physician or the nonphysician provider (NPP) who is billing for the service.
The ROS and PFSH can be recorded on an office health history questionnaire completed by the patient or ancillary staff and reviewed by the physician or NPP of record. The data may then be documented or dictated into the orthopaedic evaluation, or the health history questionnaire may be referred to by date in the note. The provider of record must sign and date the form indicating his or her review and agreement with the information on the questionnaire. Credit may not be granted if the form is only referenced in the documentation.
The ROS is an inventory of 14 body systems focusing on a description of symptoms (chest pain or shortness of breath) rather than diseases (myocardial infarction or chronic obstructive cardiopulmonary disease). To receive credit for a system review documented on a questionnaire, an individual entry of positive or negative response for each system is required. If a system is left blank, it is assumed that the patient or staff did not complete the form in its entirety.
The PFSH is a review of three areas: past history, family history, and social history.
Because every note must be a stand-alone note, a physician or NPP who chooses to refer to the ROS or the PFSH on a health history form must initially sign the form and then reference the form by date in future notes (“ROS, PFSH reviewed from March 1, 2010, no changes” or “…changes as follows…”).
Physical exam component
Most orthopaedic surgeons use the Musculoskeletal Single Specialty Examination (MSSE), which includes both a general examination and six musculoskeletal areas: neck, back, right and left upper extremities, and right and left lower extremities. Each examined area should be described in the report. The description should include inspection/palpation, range of motion, stability, and strength.
Orthopaedists who prefer to use the multisystem examination instead of the MSSE should check the AAOS Musculoskeletal Coding Guide or CMS guidelines for information.
Medical decision-making component
The medical decision-making component has three parts: data, diagnosis, and risk. It is a measure of the complexity of the case and the recorded evaluation. Medical decision-making is more complex for patients who undergo multiple tests or have multiple diagnoses, or who have increased risk factors. Any invasive procedure has a risk of morbidity and mortality. The physician should document all the data reviewed, the comorbidities considered, and the risk factors reviewed.
In some cases, time may be a factor in determining the level of service. Although time is not one of the three key components in selecting a level of service, time can become the determinant for CPT code selection when the visit consists predominantly of counseling or coordination of care. The total time must be spent face-to-face between the physician (or NPP) and the patient; more than half of that time must be spent counseling or coordinating care, and the content of those activities should be summarized. Time spent reviewing records while the provider is not with the patient does not qualify. Time should be rounded down, not up.
Modifiers are 2-digit codes that can be appended to evaluation and management (E/M) services to indicate the physician or NPP has provided a service that is variant to the normal definition or surgical package.
E/M codes should not be billed for services related to the surgical procedure during the global period. E/M services for conditions at other anatomic locations than the global surgical procedure may be reported during the global period if the medical necessity of performing an E/M service is supported and the documentation supports the level of service. For example, if the orthopaedist treats a patient for a newly sprained wrist during the postoperative global period for a total knee arthroplasty, the orthopaedist may bill for treatment of the wrist using a modifier that indicates the visit is unrelated to the global surgical procedure.
E/M codes should not be billed the day of or the day before a surgical procedure unless the decision for surgery was made at that time and the appropriate modifier is appended.
E/M codes should not be billed with planned injections. If the decision to perform the injection is made on the same day the injection is given, an E/M code with a modifier and an injection procedure code may be billed if the medical necessity of performing an E/M service is supported and the documentation supports the level of service. If the patient returns for a planned injection, however, only the procedure code should be submitted.
E/M modifiers enable E/M services to be billed with additional services that might otherwise be considered bundled in a global fee. CPT modifiers that can be used with E/M coding are listed in Table 4, found in the online version of this article at www.aaosnow.org
The use of office forms and templates can greatly simplify documentation of orthopaedic evaluations, but the physician should customize the template for each specific patient condition. Fixed templates that produce identical notes for every patient are red flags and present significant risk to the practice.
James Davidson, MD, practices with Canyon Orthopaedic Surgeons, OSNA, in Phoenix. The author acknowledges the assistance of Blair Filler, MD, and Brad Henley, MD, MBA, of the AAOS Coding, Coverage, and Reimbursement Committee and Mary LeGrand, RN, MA, CCS-P, CPC, of KarenZupko & Associates, Inc., in preparing this article. This information is for reference use only and does not constitute the rendering of professional consulting or legal advice by the AAOS or the author. Refer to the practice management center on the AAOS Web site, and submit specific questions to KarenZupko & Associates, Inc.