It’s an all-too-frequent problem in anesthesiology: The physician fails to document key information in cases involving the surgical repair of fractures of the long bones. The result can be a delay in claims submission and a resulting lag in collections.

The lapses involve procedures requiring fracture repair including Open Reduction with Internal Fixation, Closed and Percutaneous repair to the femur, tibia, fibula, humerus, ulna or radius.

Anesthesia notes frequently fail to describe the surgical procedure’s location, (e.g., proximal, shaft or distal). Because each location on the bone is assigned a separate CPT® code, and because base units differ between proximal and distal, claims without this information require additional work to help ensure proper reimbursement. If the location is not available in the anesthesia notes, additional information will need to be obtained.  

The problem reflects the fact that many physicians aren’t aware of the large number of codes available for fracture repair procedures.

A similar reoccurring problem involves anesthesiologists’ failure to specify whether the repair of a mal-union or non-union fracture includes a bone graft from the iliac crest. 

By including necessary details like procedure location and iliac crest grafting, physicians can support a more efficient coding and claims process and help minimize delays in reimbursement. At the same time, they’ll be better prepared for next year’s ICD-10 coding transition, since the new code set will demand that physicians document significantly more anatomical detail. 

For example consider the following:

ATC ANE failure to document location

Important facts:  Documentation is always KEY. ICD-10-CM has added the component of laterality, meaning some codes will indicate whether the condition occurs on the left, right or bilateral. Some sections may provide codes for conditions that are bilateral, if not then assign separate codes for both the right and left side. There is also a code for unspecified side, although it would be beneficial to be as specific as possible.

ICD-10-CM has also added 7th character for some of the chapters. This example falls in Chapter 19, which requires a 7th character. There are anywhere from 3 – 15 7th characters to choose from depending on the code and guidelines. The example above involves the following:

  • A - initial encounter for closed fracture
  • K - subsequent encounter for closed fracture with nonunion          
  • P - subsequent encounter for closed fracture with malunion

Source: CPT 2014 Professional Edition, American Medical Association (AMA), Volumes 1 and 2 (2014) and The Complete Official Draft Codebook ICD-10-CM, AMA, Chapter 17 (2015).

This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of Pathology.  This commentary does not supplant the American Medical Association’s current listing of CPT codes, its documentation in the annual CPT Changes publications, and other related publications from AMA, which are the authoritative source for information about CPT codes.  Please refer to your 2014 CPT Code Book, annual CPT Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the AMA. The AMA is the owner of all copyright, trademark and other rights to CPT and its updates.

Author - Female

About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services