Orthopedic Medical Coding Cheat Sheet: Everything You Need to Know

Orthopedics treat musculoskeletal conditions. Which is largely involved with the curing, prevention, and management of abnormalities, diseases, or complications of the skeleton and structures directly associated with it. Therefore, there is no doubt that orthopedic medical coding is difficult because orthopedic procedures and diagnoses are complex. Orthopedics coding should be done correctly to facilitate a correct billing process and correct reimbursement. 

Also, they help in ensuring that, costly mistakes are prevented altogether. In this blog post, you will find an Orthopedic Medical Coding Cheat Sheet including some important code tips, bear guidelines for some common procedures like Joint Replacement, Fractures, Arthroscopy, etc.

What is Orthopedic Medical Billing and Coding?

Orthopedic medical billing and coding is quite a complex process. It entails conveying health care services in orthopedics which is a branch related to musculoskeletal conditions into specific codes to receive the right amount of reimbursement. There is also a need for more documentation as it relates to the codes given for diagnosis, treatment, and procedures to be well compensated.

The specialty of orthopedics is very broad as it includes complex surgeries, physical therapy, and patient progress monitoring. Thus, coding is necessary to reduce the number of denied claims. Here are the key points that make orthopedic medical billing and coding unique.

• ICD-10 classification for Bone fractures and dislocation, joint Injuries, and soft tissue disorders.
• CPT Codes for operations including joint replacement treatments or arthroscopies.
• Modifiers are used to indicate bilateral procedures or post-operative care.

Related: Orthopedic Billing: The Best Practices to Get Faster Reimbursements (Coding Cheat Sheet)

Orthopedic Billing and Coding Cheat Sheet

Here is the cheat sheet for orthopedic billing and coding. But before going through, you need to know the basic definition of common orthopedic procedures. 

It means frequently performed treatments of orthopedic, interventions, and their respective codes for swift reference. This resource is a valuable tool for medical coders to select accurate codes for orthopedic procedures during the billing process.

1. CPT Codes for Orthopedic Billing

CPT codes are used to detail the procedures and services provided by orthopedic specialists

Evaluation and Management (E/M)	– Office Visits – Consultations – Established Patient Visits	– 99201-99215 – 99241-99245 – 99217-99233
Surgery	Joint Replacement – Hip – Knee – Shoulder	– 27130 – 27134 – 29880 – 29881 – 29870
Fracture Repair	– Open Reduction and Internal Fixation – Closed Reduction and Immobilization – Arthrotomy	– 29500-29599 – 29501-29510 – 29890-29899
Arthroscopy	– Shoulder – Knee – Elbow – Hip	– 29870 – 29880 – 29875 – 29873
Anesthesia	– General Anesthesia – Regional Anesthesia – Monitored Anesthesia Care	– 00100-00199 – 01900-01999 – 01710-01799
Radiology	– X-rays – Computed Tomography – Magnetic Resonance Imaging – Ultrasound	– 73570-73649 – 70010-70020 – 76470-76479 – 76570-76579
Medicine	– Injections – Physical Therapy – Occupational Therapy	– 20550 – 20610 – 97001-97161 – 97530-97549

2. Orthopedic ICD-10 Codes

These codes are for diagnosing diseases or orthopedic abnormalities and also for different kinds of fractures, disorders of joints, and other muscular or skeletal injuries. ICD-10-CM codes are essential for reporting the diagnosis or the treatment purposes and adequate payments.

Cervical Spine Disorders and Displacement

• Cervical disc disorder with myelopathy and radiculopathy: M50.00 – M50.13
• Other cervical disc displacements and other cervical disc degeneration: M50.20 – M50.33
• Other cervical disc disorders: M50.80 – M50.83
• Cervical disc disorder: M50.90 – M50.93

Neck and Back Pain

• Cervicalgia: M54.2
• Sciatica: M54.30 – M54.32
• Lumbago with sciatica: M54.40 – M54.42
• Low back pain: M54.5
• Pain in thoracic spine: M54.6
• Other dorsalgia: M54.89
• Dorsalgia: M54.9

Osteoarthritis of the Hip

• Bilateral primary osteoarthritis of the hip: M16.0
• Unilateral primary osteoarthritis: M16.10 – M16.12
• Bilateral osteoarthritis resulting from hip dysplasia: M16.2
• Unilateral osteoarthritis resulting from hip dysplasia: M16.30 – M16.32
• Bilateral post-traumatic osteoarthritis of the hip: M16.4
• Unilateral post-traumatic osteoarthritis: M16.50 – M16.52
• Other bilateral secondary osteoarthritis of the hip: M16.6 – M16.7
• Osteoarthritis of the hip: M16.9

Osteoarthritis of the Knee

• Bilateral primary osteoarthritis of the knee: M17.0
• Unilateral primary osteoarthritis: M17.10 – M17.12
• Bilateral post-traumatic osteoarthritis of the knee: M17.2
• Unilateral post-traumatic osteoarthritis: M17.30 – M17.32
• Other bilateral secondary osteoarthritis of the knee: M17.4 – M17.5
• Osteoarthritis of the knee: M17.9

 Radiculopathy

• Radiculopathy: M54.10 – M54.18
• Sciatica: M54.30 – M54.32

Rheumatoid Arthritis

This PDF has the list of all Rheumatoid Arthritis: ICD-10 for Orthopedics. 

3. HCPCS (Healthcare Common Procedure Coding System)

HCPCS codes, particularly Level II, are used to report orthopedic services, devices, and supplies that are not covered under CPT codes.

• Orthotic procedures and services: L0112-L4631
• Cervical and thoracic orthotics: L0112-L0220
• Lumbar-sacral orthotics and accessories: L0621-L0651
• Spinal orthotics and scoliosis devices: L0700-L1499
• Hip, knee, and ankle-foot orthotics: L1600-L2136
• Additions for lower extremity orthotics: L2180-L2999
• Orthopedic footwear and shoe modifications: L3000-L3485
• Upper extremity and shoulder orthotics: L3650-L3999

4. Modifiers

Here are the Common modifiers for Orthopedic Billing and Coding:

• Modifier -RT and -LT: Use ‘-for the procedure performed on the left/right side of the body, for instance, 27447-RT = Rt knee replacement.
• Modifier -59: Specifies that it is done separately from other procedures done in the same session especially when doing an unbundle of services during orthopedic surgeries.
• Modifier -50: Applied to bilateral procedures, which means the same procedure is done on both sides of the body, for instance, 27447- 50 for both knees replacement.
• Modifier -51: Added to minor surgical codes meaning that the original surgery is performed more than one time in the same operation session.
• Modifier – 78: This is applied when a physician re-enters the operating room at a postoperative time for a related, unrelated but expected procedure, for example, CPT 27253-78-RT.
• Modifier 25: Reported when E/M services are provided on the same day as minor procedures if the code for the footnote service is significantly distinct from the code for the procedure.
• Modifier 57: It is utilized when an E/M service leads to the decision to operate, most often when major surgery is to be done during the same session or shortly thereafter.

The annually updated CPT codes and HCPCS codesets are available here – Centers for Medicare and Medicaid Services.

Common Challenges Involved in the Orthopedic Billing and Coding Procedures

During the process of orthopedic billing and coding, there may few challenges. Navigating these challenges is crucial. Failing to navigate these challenges may result in denials.

1. Not Verifying Medical Insurance During the Initial Stage

• Healthcare practice staff members should initially collect patient insurance information and verify the coverage details. 
• This process needs to be done before the service is rendered. 
• Failing to do this process may lead to claim denials and unexpected billing for patients which could surprise them.

2. Budling Errors

• Certain treatments and services are not allowed to be paid separately.
• Unbundling is a process of classifying and billing services that need to be combined into a single CPT code.
• Unbundling may result in overpayment. 
• Regulations and guidelines govern the bundling of services to avoid overbilling and guarantee that healthcare practitioners are paid fairly for the services they render. 
• To prevent incorrect bundling and overpayment of services, CMS and NCCI modifications offer thorough instructions and code modifications.

3. Avoiding Insurance Payer Guidelines

• Each insurance payers have specific guidelines. 
• They specify how a service has to be coded, recorded, and invoiced. 
• The two key payer concepts that influence whether to approve or reject a surgery or service rendered by the provider are medical necessity and previous authorization.
• A better understanding of the payer guidelines is necessary to ensure accurate payment for services that could otherwise be rejected.

4. Inappropriate Documentation

• Documentation is an important aspect of orthopedic billing and coding.
• It is important to get properly reimbursed and maintain integrity.
• Inaccuracy, missing, or mistakes in documentation can lead to an increase in the risk of payer and CMS audits.
• It can also have negative effects on patient treatment quality and increase the risk of malpractice lawsuits. 

5. Failure to Stay Updated with the Changing Codes

• CPT and ICD-10-CM codes are deleted and revised on an annual basis. 
• Healthcare practitioners must stay up to date on current coding guidelines and updates to guarantee accurate and compliant claim coding and billing.

Learn More – Orthopedic

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