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Protecting and
Maximizing your Revenue
Cycle in 2014
2014 Coding and Fee Schedule Updates,
Revenue Cycle Management Strategies and ICD-10

 HIS is a Physician management organization that specializes

in managing the revenue cycle for Orthopaedic practices.
 HIS has over 20 years of experience partnering with

Orthopaedic practices.
 We have earned the trust of our clients and we are viewed as

experts and leaders in the Orthopaedic community.
 HIS is an organization that partners with Orthopaedic

practices to maximize reimbursements, increase workflow
efficiency, ensure compliance and improve overall
profitability
2

2014 Coding and Fee
Schedule Update
Stay up to date and compliant to protect your Revenue Cycle in 2014

2014 Coding and Fee Schedule
Updates
 Revisions to CPT tumor codes
 Coding Changes
 Shoulder and Elbow

 New Category III codes
 CMS Final Rule changes 2014
 NCCI Policy Changes 2014
 E&M Audits

4

Revision to Subcutaneous
Soft Tissue Tumors
 All sub-sections of 20000’s have

revisions to these CPT® codes
 Clarifies that these tumors are in the

soft tissue below the skin.

5

2014 CPT Revision
Example of “malignant neoplasm” has

been removed from all codes for radical
resection of a tumor and replaced with
sarcoma.
24077- Radical resection of tumor

(eg, malignant neoplasm sarcoma), soft
tissue of forearm and/or wrist area; less
than 3 cm
6

2014 CPT Changes
 23333- Removal of foreign body, shoulder; deep
 23334- Removal of prosthesis, included

debridement and synovectomy when
performed; humeral or glenoid component
 23335- humeral and glenoid components
 Removal should only be billed if not being

replaced
7

Shoulder Prosthesis
 Deleted 23331, 23332- old codes needed update
 Technique changed- removal more difficult
 Replaced with
 23333- Removal of foreign body deep (below fascia
and/or intramuscular
 23334- Removal of prosthesis, humeral or glenoid

component- debridement and synovectomy
included
 23335- Removal of prosthesis, humeral and
glenoid components (total shoulder)
8

Elbow Prosthesis Removal
 RUC requested 24160 code description be

revised.
 24160 and 24164 describe prosthesis vs. implant

 Current method of elbow arthroplasty includes

the use of cement which makes removal more
difficult
 Special machines are needed for removal
9

2014 Category III Additions
 0334T- Sacroiliac joint stabilization for

arthrodesis, percutaneous or minimally
invasive(indirect visualization), includes obtaining
and applying autograft or allograft when
performed, includes image guidance (CT or fluoro)
when performed
 Several parentheticals that note to use this code
for percutaneous arthrodesis

 0335T-Extra-osseous subtalar joint implant for

talotarsal stabilization

10

CMS Physician Fee for Service
Final Rule 2014
Misvalued Codes: Consistent with amendments made by the
Affordable Care Act, CMS has been engaged in a vigorous effort over
the past several years to identify and review potentially misvalued
codes, and make adjustments where appropriate. We are continuing to
make strides as the values for around 200 codes were finalized and
approximately 200 additional codes had their work relative value units
changed on an interim basis for 2014. Included in these are services for
hip and knee replacements, mental health services and GI endoscopy
services. These rates are open for public comment until January
27, 2014.
 http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-

Sheets/2013-Fact-Sheets-Items/2013-11-272.html?DLPage=1&DLSort=0&DLSortDir=descending
11

Hip and Knee Arthroplasty
27130, 27447- CMS High Expenditure

27446- Harvard-valued service annual
approved charges exceed $10 million
Methods have changed causing this to
be possibly misvalued
12

Intra-operative Minutes
2005

Current

27130

135

100

27446

105

90

27447

124

100

13

2014 Final Rule
Code

Description

2013

2014

27130

Total Hip

$1,662.85

$1,581.00

27447

Total Knee $1,774.92

$1,579.89

76942

Ultrasound
Guidance

$220.46
14

$78.71

2014 NCCI Policy Manual

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.htm
l?redirect=/nationalcorrectcodinited/
15

2014 Chapter 4 Page IV- 6
4. With the exception of the knee
joint, arthroscopic debridement should not be
reported separately with a surgical arthroscopy
procedure when performed on the same joint at
the same patient encounter. For knee joint
arthroscopic debridement see the following
paragraph.

16

2014 Chapter 4 Page IV-7
6. Arthroscopic synovectomy of the knee may be reported with CPT
codes 29875 (limited synovectomy, “separate procedure”) or 29876
(major synovectomy of two or three compartments). A
synovectomy to “clean up” a joint on which another more extensive
procedure is performed is not separately reportable. CPT code
29875 should never be reported with another arthroscopic knee
procedure on the ipsilateral knee. CPT code 29876 may be
reported for a medically reasonable and necessary synovectomy
with another arthroscopic knee procedure on the ipsilateral knee if
the synovectomy is performed in two compartments on which
another arthroscopic procedure is not performed. For
example, CPT code 29876 should never be reported for a major
synovectomy with CPT code 29880 (knee arthroscopy, medial AND
lateral meniscectomy) on the ipsilateral knee since knee
arthroscopic procedures other than synovectomy are performed in
two of the three knee compartments
17

2014 Chapter 4Page IV- 10
14. If a single cast, strapping, or splint treats multiple closed fractures
without manipulation, only one closed fracture treatment without
manipulation CPT code may be reported. Additionally, if a single
cast, strapping, or splint treats multiple fractures without
manipulation in addition to one or more fracture(s) with
manipulation, a closed fracture without manipulation CPT code
should not be reported separately. These policies also apply to the
closed treatment of multiple fractures not requiring application of a
cast, strapping, or splint.
If a cast, strapping, or splint applied after an open or percutaneous
treatment of a fracture also treats a closed fracture without
manipulation, a closed fracture without manipulation CPT code
should not be reported separately.
18

CMS Allows ’97 Extended HPI with ’95 Guidelines
September 27th, 2013
Effective Sept. 10, the Centers for Medicare & Medicaid
Services (CMS) has revised its Evaluation and Management
(E/M) Documentation Guidelines (DG), to allow physicians to
use the 1997 DG for an extended history of present illness
(HPI) with the other elements of the 1995 DG to document an
E/M service. As a result, “the status of three or more chronic
conditions” qualifies as an Extended HPI for either set of DGs.

The revised guideline is presented as a Question and
Answer on the CMS website:
19

Who’s Looking
 OIG
 CMS-CERT, RAC
 Cigna
 Humana
 Workers Compensation

21

NGS Prepay Audits
Current procedural terminology (CPT) codes 99205
and 99215 are in the top 15 codes identified for
improper payment rates.
If one of your claims is selected for review, you will
receive an Additional Documentation Request
(ADR) letter. You will have 30 days from the date of
the ADR to submit the requested documentation
 www.ngsmedicare.com Part B New Article October

1, 2013
22

New Patient Visits 2011
Orthopaedics
1600000

1400000

1200000

1000000

800000

600000

400000

200000

0
1

2

3

23

4

5

Established Patient Visits 2011
Orthopaedics
6000000

5000000

4000000

3000000

2000000

1000000

0
1

2

3

24

4

5

Purpose of Auditing
 Bills are accurately coded and accurately reflect the services

provided (as documented in the medical records);
 Documentation is being completed correctly;
 Services or items provided are reasonable and necessary; and
 Any incentives for unnecessary services exist.

25

What to Audit
 How many records reviewed per provider?
 Medicare or All patients
 Prospective not Retrospective

26

Reporting Results
 Document findings and keep as permanent

records
 Medical Records
 Summary
 Information shared with Provider(s)
 Spreadsheet

27

After the Audit
 Create protocol
 Determine training means
 Mandate Training

28

Provider Training
 In Person (one-on-one)
 Webinar/Module
 Newsletter/Worksheet

29

4 Critical Functions of Your
Revenue Cycle that
Cannot be Ignored

Customer Service & Satisfaction
 Customer service
 Patient focused effort
 Managing Patient expectations and complaints

33

Front End Strategy
 Time of Service Collections
 Pre-Cert and Authorizations
 Pre-Verification
 Scheduling
 Patient phone call management
 Inbound and outbound
34

Optimal Coding
 ICD-9 (10) and CPT selection
 Documentation
 Appeals
 Measuring
 Audits

35

Education & Training
 Certified Coders
 One on One Relationship with physician
 Open communication
 Physician training
 ICD-10

36

Charge Capture & Reconciliation
 System of accountability
 Every service rendered accounted for and billed
 Reconciliation
 Frequent reconciliation with multiple check points through out

your revenue cycle
 Missing Encounter report
 Including DME
 Inventory management
 Ensure everything is billed and accounted for
 Cost of goods analysis

 Strategic Audits
37

Developing a complete Accounts
Receivable Strategy
 Thorough understanding of your payors
 Know Your Contracts
 Credentialing and revalidation
 Certification and Pre-Authorization Requirements
 Timelines relative to submission and appeals
 Contract rates and payment adherence
 Reimbursement Tracking
 Fee schedule changes
 Are your rates competitive with the prevalence of

transparency in cost
38

Developing a complete Accounts
Receivable Strategy
 Managing Insurance Denials
 Consistent methods, efficient protocols and

resolution
 Denial Trending
 What are you doing with that information ?

 Identify systemic issues
 Rectify and route to appropriate personnel

39

Establish your A/R Assembly Line
 Detailed Management of the A/R
 CPI (Critical Performance Indicators)
 Reporting and Trending
 By Payor
 By Physician
 By Service Type

 Pay attention to the details in the Reports
 Understanding the details behind the reports will mean increased
collections and lowered D/O
 Payor claim habits


Set up protocols

 Control over processes and measure to the details
40

Collecting from the Patient
 Patient Balances
 Toughest position in your Rev Cycle
 Right people in the right job

 Follow a practice policy
 Do you see patients w/ outstanding balances ?

 Speed and efficient techniques
 Staff training and motivation
 Do not ignore small balances
41

Create a Successful &
Repeatable Process
Measure
Manage
Modify
And Repeat

42

ICD-10 Readiness
Actionable steps to get your practice ready for the October 2014 transition

ICD-10 Facts to Consider
 There are two code sets for ICD-10
 ICD-10-CM- Fee for service code set
 ICD-10-PCS- Facility code sets
 Transaction code sets were officially approved

in HIPAA Act of 1996
 CPT,ICD-9, HCPCS
 Workers Compensation, auto, and personal

liability insurance are exempt from HIPAA
45

How To Prepare
 Impact Analysis
 Education
 Costs
 Preparedness
 Revenue

46

Impact Analysis
 Choose representative from each area of the practice
 Analysis is performed
 Readiness survey is given

 ICD-10-CM Committee should analyze all of the needs
 Identify and mitigate risks
 Create the Analysis based on results
 Classify issues by impact
47

Impact Analysis
Impact

Definition
Affects fundamental
functions
Objectives will be
accomplished
Can cause some negative
affects

Very High
High
Moderate
Low

Can cause minor affects
48

Impact Analysis
 Create document to report each business

area that will need to be adjusted by:
 Policy
 Process
 System
 This will allow for better assignment of

work based on impact
49

Education
 Who needs education

 Everyone
 Administrative
 Front Office
 Clinical
 Coders
 Other Back Office Staff
 Physicians and NPP

 Recommendations for Coder Training range from 16-40

hours with a refresher in Anatomy and Physiology
50

Impact Analysis - Education
Impact

Definition

Very High

Coding Staff Training

High

Physician Training

Moderate

Clinical Staff Training

Low

All Others
51

What is this missing?
PRESENT HISTORY: Ms. returns to see me now one year from her operation at her midfoot. She has been doing
reasonably well in the sense that she does feel that she does have improvement of her pain relief as she had been
prior to her surgical reconstruction. I wanted to make this clear today with her and I asked her if she is better off
than she was prior to surgery and she says yes.
PHYSICAL EXAMINATION: Examination shows that her surgical wounds look good. Her foot alignment is
neutral. She still does have complete restoration of her medial column or arch. Her tenderness is present
dorsally about the first metatarsophalangeal joint. She has equal tenderness present plantarward, which is at the
site of the FHL tendon. Now this is at the level of the proximal phalanx. She however does have good push-off
power against resistance. She has no evidence of hallux flexus deformity and no evidence of a claw toe deformity
present there.
IMPRESSION:


Healed first metatarsocuneiform joint arthrodesis with osteotomy, modified McBride bunionectomy, Akin
osteotomy, second metatarsocuneiform joint arthrodesis, ostectomy medial cuneiform and navicular for bossing
with removal of loose body and anterior tibial tendon repair.



Two hallux rigidus, osteoarthritis, first metatarsophalangeal joint with flexor hallucis longus tenosynovitis plantar
grade toe.



Residual inflammation midfoot

52

Site and Laterality
 Most codes related to musculoskeletal conditions have

site and laterality designations.
 Site represents
 Bone
 Joint
 Muscle
 Multiple sites code

 If there is no multiple site code, multiple codes should

be used
53

Acute Vs. Chronic or Recurrent
 Many musculoskeletal conditions result of previous injury or

trauma to a site, or are recurrent conditions.
 Chapter 13 has
 Chronic or recurrent bone, joint, or muscle conditions

 Conditions that are the result of healed injury

 If it is difficult to determine acute or chronic, query the

provider
 Acute injury coding is in Chapter 19

54

Fractures
 Displaced or non-displaced
 Fracture type (2,3,or 4 part)
 What kind (greenstick, communited, transverse)

 Routine healing, delayed

healing, malunion, nonunion

 Open or closed
 Open breaks down further (Type I, II,IIIA,IIIB,IIIC)
 Salter-Harris Fractures
55

Sneak Peak at ICD-10-CM
824.1 Fracture of ankle; medial malleolus, open
S82.56XC Nondisplaced fracture of medial malleolus of
unspecified tibia, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.56XB Nondisplaced fracture of medial malleolus of
unspecified tibia, initial encounter for open fracture type I or II
S82.53XC Displaced fracture of medial malleolus of unspecified
tibia, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.53XB Displaced fracture of medial malleolus of unspecified
tibia, initial encounter for open fracture type I or II
56

Fracture Comparison
POSTOPERATIVE Left open femoral shaft fracture
INDICATIONS FOR PROCEDURE:
 The patient is a 27-year-old female involved in a high-speed

motor vehicle accident, sustained a grade 2 open left distal
femoral shaft fracture with comminution. Femoral neck was
visualized and seen to be okay.
 X-ray showed excellent reduction.
 ICD-9 821.11
 ICD-10 S72.355B
57

Preparedness
 No grace period
 Coding based on date of service
 Premature coding
 Testing

58

Impact Analysis - Preparedness
Impact

Definition

Very High

Practice Management
System

High

System Testing

Moderate

Pre-Coding

Low

EHR
59

Costs
 Training
 Practice Management Upgrades
 Temporary staffing or over time

60

Impact Analysis- Costs
Impact

Definition

Very High

Training

High

Software Programs

Moderate

Staffing

Low

Encounters/Superbills
61

Office Superbill/Encounter
 Paper Superbill/Encounter may be impossible
 Providers document in writing to be coded
 Electronic Encounter

 EMR capabilities

62

Revenue
 Reduced revenue:
 4th Quarter of 2014 & 1st Quarter 2015
 Loss in Productivity
 Delays in reimbursement
 Increase in claims denials

63

Impact Analysis- Revenue
Impact
Very High

Definition
Insurance Carrier /Delays
in Claims Processing

High

Staffing

Moderate

Slow down in office flow

Low

Holiday Season
64

For follow up questions feel free to contact
us:
Andy Salmen, Business Development HIS
P: (847) 720-7007
E: asalmen@healthinfoservice.com
www.HealthInfoService.com

350 S. Northwest Highway, Suite 200
Park Ridge, Illinois 60068
(855) RING-HIS
66

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Protecting and Maximizing Your Orthopedic Revenue Cycle in 2014

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