Pre-op vs Post-op Diagnosis

Question:

Is there a difference between a pre-operative diagnosis and a post-operative diagnosis?

Answer:

Pre-operative diagnosis is based on the “Reason for the surgery” or the condition affecting the patient leading to the necessity of the surgery. Underlying co-morbidities that can affect the surgical outcome or represent a risk to the patient can also be included but the documentation must support their relationship to the patient risk.

Post-operative diagnoses are based on the findings determined during the surgical procedure.  Post-op diagnosis may be the same as the pre-op diagnosis or may be more definitive.

*This response is based on the best information available as of 12/19/24.

Which Modifier Should I Use?

Question:

I need some help with using Modifiers. I work for a Mohs surgeon, and he frequently performs Mohs, and the patient comes back differently for a flap or graft. They usually come back within a week. What modifier should I add to the repair when the patient returns?

Answer:

Mohs Micrographic surgery has a global period of “0” days. That means if the patient comes back for the repair on a different date, no modifier is required. 

*This response is based on the best information available as of 12/19/24.

Periprosthetic fractures ICD-10

Question:

I'm new to coding ortho and I am very confused on how to code periprosthetic fractures. I was under the impression that only one ICD-10 was required for this type of fracture (M97.x). What am I missing?

Answer:

There is a category of codes in ICD-10, specific to Periprosthetic fractures around internal prosthetic joints, and the category is M97. When referring to the tabular section of ICD-10, under M97 category there is an instructional note which states the following: code first, if known, the specific type and cause of the fracture. That being said, if the documentation reflects the site and type of fracture while also identifying this as a periprosthetic fracture around an internal prosthetic joint, you will assign the primary ICD-10 code for the known fracture, followed by ICD-10 from M97 series to identify the periprosthetic fracture for the specific joint. 

Example: Displaced comminuted periprosthetic fracture of the proximal shaft of the right femur, patient status post right total hip replacement. 

ICD-10 codes: 

1) S72.351A 

2) M97.01XA 

Let's take this one step further, according to ICD-10, if you have a periprosthetic fracture around a prosthetic joint in which there is no specific code, then you would report M97.8XX-, and then use an additional ICD-10 code to identify the joint Z96.6-. The ICD 10 instructions for M97 instruct to code first, if known, the specific type and cause (e.g. pathologic or traumatic). If you read on to M97.8, there are additional instructions to also report the appropriate joint (Z96.6-). As you can see, the instructions and hierarchy are a bit different when there is a specific joint arthroplasty code versus not. 

Example: Displaced comminuted periprosthetic fracture of the right distal radial shaft, patient status post right wrist arthroplasty. 

ICD-10 codes: 

1) S52.351A 

2) M97.8XXA 

3) Z96.631 

*This response is based on the best information available as of 12/19/24.

Ear Hairs

Question:

If a patient comes in with ear pain due to loose ear hairs in the ear and the provider removes the hairs with alligator forceps, can it be billed as a foreign body removal?

Answer:

Ear hair(s) are not considered foreign bodies as they are a natural protectant to the inner ear and function to work with earwax to keep the canal clean and debris away from the eardrum.

As such, even though the hair is loose or dislodged, there is not a reportable CPT code for this. The work for removing the hairs is Included in the work for the E/M service, assuming there was a medical necessity for an E/M service (e.g., evaluation of ear pain).

*This response is based on the best information available as of 12/19/24.

Counting the Number and Complexity of Problems Addressed

Question:

Would cervical and lumbar radiculopathy count as one or two problems, and are they considered acute, chronic, stable, or not stable on the table of risk?

Answer:

Good questions! First, the number of problems would be two since these are different body parts, and each will require its own diagnosis and treatment recommendation.

The next is issue is, are the presenting problems acute or chronic, and that will require a good history of present illness, detailing how the problem presented. Was it an injury? Is it degenerative, so by the very nature of degenerative disease it is chronic. An accurate selection of where the problems “fit’ within the problem element cannot be determined without a good history.

*This response is based on the best information available as of 12/19/24.

Percutaneous Fracture Fixation

Question:

Our surgeon performed a closed reduction of a medial malleolar fracture with percutaneous fixation. There is no documentation of an open reduction, and we are unsure how to report this procedure.  

Answer:

Percutaneous fixation of a medial malleolar fracture is reported with an unlisted code, 27899. Work with your surgeon to identify a comparison code; one option is CPT code 27762 (Closed treatment of medial malleolus fracture with manipulation, with or without skin or skeletal traction).  

*This response is based on the best information available as of 12/5/24.