Author

Alan Pechacek

I am a retired general orthopedic surgeon who practiced full-time for forty years. I was with a four-man orthopedic group for four and a half years. I practiced alone for the next 12.5 years then spent the last 24 years of my career in the Orthopedic Department of a multi-specialty clinic.

When I started practicing in 1974, diagnosis and procedure coding was essentially nonexistent. The ICD-9-CM volumes were available, but they were seldom used. During the years of my time in solo practice, starting in 1979 and continuing through mid-1991, the requirements for diagnosis and procedural coding evolved and became essential for the purposes of billing and reimbursement. Since I was the only person to do this (coders did not really exist at that time), I had to learn how to do it for myself.

In the 1980s, when arthroscopy and arthroscopic surgery exploded onto the scene, there were no codes for arthroscopic procedures, and I had to develop my own system for them, including establishing a "relative value" for the various procedures that I did. Eventually, the CPT Coding books started to include the various and assorted arthroscopic procedures. My particular scheme and the CPT codes were amazingly similar. In 1991, when I relocated and joined a multi-specialty clinic that had capable coders for our department, I continued to do my own coding for hospital and surgical patients. As for working in the office, I had memorized most of the diagnosis codes from ICD-9, such that I could write those down out of my head. The same could be said for most of the procedural coding. I did my coding and then sent it to our departmental coder so she could enter the information into the claim forms. Insofar as I rarely was contacted by her regarding my coding, I can only come to the conclusion that she was using my codes as I had sent them to her and considered them to be correct, or she was ignoring them completely and throwing them in the trash. I would like to think that the first conclusion is correct.

I do not consider myself to be an expert, nor am I a certified coder, but I believe my long, in-the-trenches learning experience for coding qualifies me to create my book.

Alan Penchacek




Position Statement Regarding ICD-10

It is my firm belief and conviction that Orthopedic Surgeons should know how to correctly code using ICD-10 in accordance with all the rules and dictates established by CMS.  In answer to the question "why?", it is because their financial present and future is dependent on it.  This is not only my opinion, but also the opinion of all of the mentors/instructors that I have learned from in the process of being educated about ICD-10.  They also strongly advocate for it.  The reason that Orthopedic Surgeons have not necessarily had to be fully involved with coding up until now is that ICD-9 was fairly simple and straightforward when compared to ICD-10, which is far more complex with more specific codes and coding requirements, plus the additional directives regarding the External Cause Codes.  ICD-10 has been mandated by the CMS and HHS for use by all healthcare involved entities.  There are many rules that are in this system that would not be there if the “Powers that Be” didn't want them there and used.  Granted, the CMS has waived the coding requirements of External Cause Codes at this time, but this applies only to Medicare, but not necessarily to Medicaid or other health insurance companies.  I would tend to believe that over time, and since we are dealing with the federal government, they may well change the rules and require External Cause Codes for Medicare at sometime in the future.  One only has to look at what has gone on with "Meaningful Use" for the electronic medical record over the last few years.  Each year since they went into effect, the requirements have changed, a combination of both "raising the bar" and "moving the goal posts."  The government gets to change its mind as it desires, and everybody else has to go along with it.  As for all the other health insurances, they are left to make up their own minds as to how detailed and/or extensive the coding will have to be to satisfy them.

During the course of my pursuit of education and training for ICD-10, I have heard from multiple Advanced Certified Coders that physicians should be engaged in this coding process.  I have listened to these Master Coders, and tried to work with some office coders, many of whom are certified themselves, but I have learned that although they are quite familiar with medical and orthopedic terminology and vocabulary, they do not have quite the insight into the medical aspects of patient evaluation and treatment.  My comments are not meant to demean them or downgrade their importance, as they are very good and important people, essential for the financial operations of any practice.  Practicing physicians could not survive without them, but they need to be made a part of “the team,” and not left stranded to do it on their own.  I believe that the thorough, complete, and accurate diagnosis coding should be the result of the team work of both the physician and the coder.  Physicians need their help, and the Coders need the help of their physicians if they are going to maximize the results.  The Coders are the final pathway through which the physician’s work passes for the filing of claims for medical care.  If the coding is not correct on the claim form in a way that satisfies the demands and requirements of the insurance company, then claim denials are very likely to occur.  If the claim is denied for lack of correct and/or complete coding, then everybody is back to square one, and no payment is received.  Everybody gets to start all over again and try to figure out what was missing or wrong, then try again.  In denying your claim, the insurance company may not be so kind as to clearly spell out what is wrong or missing.  They may well leave it to the physician and his coder to figure that out for themselves.  This is time consuming, wasteful, and costly.  I believe that if both the physician and the coder are fully engaged in this coding process, and are working together, then there should be far fewer denials, and a better inflow of payments.

Health Insurance companies do not want to pay out money.  They believe in getting money into their accounts from the payment of premiums, but have no interest in sending money out.  Since the insurance companies are in the business of "business," they are interested in earning money/profits for themselves and their shareholders.  The money they have in their hands is invested so that it continues to grow through interest or dividends.  The longer they can hang onto it, the wealthier they become.  There are some principles of Economics that come into play.  The first is that people/organizations respond to incentives.  The incentive for the insurance company is to keep the money in their accounts so it keeps growing and adding to their financial success.  To pay money out on claims would be considered a negative incentive, something they would not want to do.  By denying claims, they continue to prosper.  There is another principle of Economics called the "Time Value of Money."  This essentially means that the value of a given quantity of money changes depending on what is being done with it.  By keeping your money in their accounts, it increases in value based on its being invested.  As for the person or group requesting payment, the value of the amount claimed loses value over time as a result of a level of economic inflation.  In a sense, the dollar degrades in value over time such that when the claimant receives his payment, it does not have the same “value” as it had at the time the claim was made.  For example, and to keep the numbers easy to work with, we will say that the return on investment to the insurance company is a nice 8% per year, or 2% per quarter/90 days.  At the same time we will say that the basic inflation rate is 4% per year, or 1% per quarter/90 days.  If a physician’s office submits a claim of $100 for patient care, and the insurance company manages to drag its feet in processing the claim for 90 days, the company earns $2 for their pocket, whereas the physician's office claim of $100 loses 1% of its value over the same 90 days, so now it is only worth $99.  After 90 days, the insurance company has $102, and the physician’s claim his only worth $99, a differential of $3.  If they can deny your claim and drag it out even longer, the differential progressively gets larger.  At another 90 days, while the physician's office reviews and recodes and re-submits the claim, the insurance company now has $104, and the physician’s $100 claim has degraded to $98.  As you can see, it is not in the best interest of the insurance company to process and pay claims quickly.  It is interesting to note that because of insurance company’s ability to stall and tinker with the claim that many states have had to enact laws requiring the insurance companies to process claims in a shorter, defined timeframe such as 30-45 days.  However, this does not get around the possibility of denying the claim for some reason, and sending it back to the claimant unpaid, but they just have to do it in a shorter period of time.  With the institution of ICD-10 Coding and all of its rules and requirements, the insurance companies now have more “weapons” and “gadgets” to use for claim denials. 

I attended an Orthopedics Today Hawaii meeting in January, 2015, at which there was a panel discussion on healthcare policy and related “business” aspects of orthopedic practice, moderated by Dr. Jack Bert.  One of the panel members was Dr. Bill Beach, who has been a leader and fighter for Orthopedic Surgery in the battle with what I will call “The Evil Empire” of CMS, HHS, (RIC, RAC, RUC, SIC, SAC, SUC, ... whatever) that try to figure out more and better ways to decrease physician compensation for the work they do.  Dr. Bert asked Dr. Beach what the “one thing” he knew for certain after all of his time and energy spent in the pursuit of “a fair day’s pay for a fair day’s work” for Orthopedic Surgeons.  His answer was “I know for certain that they are out to screw us.”  Therefore, I am not the only person with this “mind set.”

Complete and accurate diagnosis coding and reporting is imperative for Orthopedic Surgeons to fight “The Evil Empire” and get paid for their work.  This requires the team work as discussed before.  Correct coding by the physician will require thorough and complete documentation of the record in order to get there.  There is an intimate relationship between the required coding “specificity” and “documentation.”  You can’t do one without the other.  By learning how and what to code, the physician learns what needs to be documented.  By knowing what documentation is necessary for correct coding, the job gets easier.  And “Wallah” once all the correct documentation is in the record, then the Coder can find it, code it, and file it on the claim, and the doctor is “off the hook.”  If and when there is a problem, such as from a complicated patient scenario, then the two of them can collaborate to solve the problem much easier and quicker.

Just a note about coding co-morbidities.  One of my Instructors, who had years of clinical experience as a nurse in inpatient and office orthopedics, made the point that coding relevant and pertinent co-morbidities, in addition or supplementary to the musculoskeletal diagnosis for which you are treating the patient, should be helpful for the claim processing.  It sort of goes back to the Utilization Review concept of many years ago called SI-IS (Severity of Illness - Intensity of Service).  This would apply to hospitalized patients in particular, as their co-morbidities could affect the decision making process for the procedure to be done and it’s timing.  It gives the insurance company information about the complexity of the patient’s orthopedic and medical problems and their care, and may help with claims processing, hopefully faster and fewer denials.  Even the Orthopedic Surgeon who may not be primarily responsible for managing these co-morbidities, submitting the codes for the them that are relevant to, and may influence the patient’s episode of care could be very helpful.  With “Care by Committee” as it happens today, I would not recommend leaving the coding of the co-morbidities to the other members of the “team,” particularly when they probably not a part of your practice group or organization.

I believe in full and complete coding from the very beginning.  Get it right from the “get-go.”  The sooner the transition from ICD-9 to ICD-10, the better.  I believe that all the necessary and appropriate codes for the Orthopedic diagnoses, and for relevant Co-morbidities, etc. should be determined and filed up front.  Give “them” everything there is, and let them decide what they want or need.  Don’t give “them” the opportunity to deny the claim on the basis of “incorrect or inadequate coding.”   The best “defense” is a strong “offense.”

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