At a recent Specialty Day talk on managing difficult worker’s compensation patients, an ASSH member had a poignant and arresting slide that simply said “Don’t Be a Rapist.” By that, he meant that it was easy to overbill, overcode, and perform unnecessary procedures on worker’s compensation patients, and that we have a moral and ethical obligation to treat these patients, and all patients, with respect and integrity. Correct coding is not only a legal requirement, it is a moral obligation.
As an orthopaedist who performs a significant number of Independent Medical Exams for Worker’s Compensation patients, I am often called upon to review the work of my colleagues. I am thankful that about 90% of the time I can say, confidently, that the treatment rendered has been reasonable, necessary and appropriate and that I would recommend continuing the course of action prescribed by the treating physician. Yet I also see some dubious things that give me pause. Recently, I have seen a patient who underwent shoulder arthroscopy where a biceps tenotomy was performed (which can be billed using a joint debridement code, 29823) but it was billed as a biceps tenodesis (23430), and the operative report justified this by saying that the biceps was released with a thick enough cuff of labrum that it would get stuck at the level of the bicipital groove. The patient eventually had to undergo a formal tenodesis because of continued anterior shoulder pain. I routinely see coding for distal clavicle excision where the surgeon merely continued the acromioplasty to the underside of the AC joint but the joint itself was left untouched.
In another case, a peripheral nerve surgeon performed neuroplasty of both digital nerves in the same finger. Because the code for neuroplasty of digital nerve says, specifically “one or both” (64702), the surgeon billed 64702 as well as 64704, claiming he did a neuroplasty on an additional branch of the median nerve. In yet another case, a surgeon placed an OnQ pump following a nerve decompression, which was removed three days later. I was unfamiliar with the code used by the surgeon and so looked it up in the CPT book. The surgeon had billed a code normally used for an invasive cardiac catheter procedure to place the pump (which, just to be clear, cannot be billed for at all if placed by the surgeon), and billed a separate code for removal of an implanted pain pump that is normally used for surgical removal of an implanted intrathecal spinal cord stimulator. These codes were reimbursed by the worker’s comp carrier for well over $5,000.
In a third case, a surgeon saw a worker’s comp patient in the emergency room for a sharp laceration to the dorsum of his thumb. The patient was taken to the OR the same day for extensor tendon repair, however the surgeon commented in the operative report that “the superficial radial nerve appeared compressed and so I performed a decompression.” The surgeon billed for neurolysis and was reimbursed. Ask yourself – if you were the surgeon, would you consider this appropriate coding? Ask yourself – if you were the patient, and you were made aware of this, how would you feel towards your surgeon? Then ask yourself, if you were the lawyer for the insurance carrier and this came to your attention, what would be your next course of action?
Coding cases often feels like another unnecessary labor, with arcane rules and poor guidance, one of the many administrative hoops we need to jump through to get reimbursed. There is a rather large cottage industry that has evolved around it, and my work email is stuffed with advertisements for coding webinars. As a member of the Coding and Physician Reimbursement Committee at ASSH, I see the behind-the-scenes work performed on the national level by many of my colleagues, especially our past president, Dan Nagle, to ensure that codes are accurate and accurately reimbursed. But I also see the lumbering bureaucratic machinery in place that turns the process into a slog. When we code inappropriately, we jeopardize all of the work my colleagues do, we set ourselves up for clawbacks and legal action, and we undermine the public’s view of hand surgeons as ethical and caring practitioners. As much as we may try to separate ourselves from the financial aspects of our practice, when we are seen as opportunistic or money-grubbing, it erodes what moral authority we still have as physicians.
There are many areas where correct coding is debatable – what codes should you use for nerve transfer or acellularized nerve allograft? What constitutes a “deep” implant versus a “superficial” implant when removed (20670 vs 20680)? There are areas where we, as hand surgeons, feel the guidance is clear but our members are still getting denials – 25447 and 20680 being coded together as the trapeziectomy/interpositional arthroplasty portion and the suspension portion, respectively, of an LRTI is a prime example. And there are now numerous instances where establishing the appropriate diagnosis code to correspond to a treatment code leads one down a rabbit hole to utter confusion. For these situations, the Coding Committee has an internal listserv to which members can submit coding questions for guidance – send an email to Olivia Moran (firstname.lastname@example.org) and coding queries can be discussed by the committee.
For those situations where I am having difficulty coding my own surgeries, my rule of thumb is to code so that if a colleague of mine were performing an Independent Medical Exam of my work, he wouldn’t raise an eyebrow; if a Board Examiner were looking at my case during my oral boards, there would be no reason to be nervous or embarrassed. Maybe this is too subtle. We can convince ourselves of the appropriateness of our actions, and the nature of our work and the risk of complications and poor results from the surgeries we perform requires that we do so. I would urge some restraint, even though it may affect our bottom line. The difference between “questionable” and “fraudulent” is in the eyes of the beholder and out of the hands of the surgeon. Coding appropriately is a moral obligation to your patients, to your insurance carriers, to yourself, and to the entirety of the ASSH.