Good afternoon. On behalf of AOFAS, I want to welcome you to the fifth session of the Crack the Codes Practice Management and Coding Course Series. Today's session is Fracture Care for the Foot and Ankle. Today's presentations will be given by Jennifer Cabrera and Jennifer Bell. You can find their full biographies and disclosures in the program document posted in the On Demand Education Center. This series is funded from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Paragon 28. I'd like to run through a few housekeeping items before we kick off the presentation. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Your physician attendees may earn one hour of AMA PRA Category 1 CME credit for this session by completing an evaluation in CME claim form at the end of the full series. Tomorrow, you will receive an email with a link to evaluate this specific session, and then at the end of the seven broadcasts, you'll be able to evaluate and claim CME for the full course. This webinar is being recorded and will be available for on-demand viewing in the On Demand Education Center as a module within this course listing in approximately 24 hours. The recording will be available for one year. We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab on your navigation bar. We cannot get to your question during the live broadcast. The faculty will reach out to you following the broadcast to respond. I will now turn the program over. Thank you. Thank you, everyone. We're just getting our slides up and running for you. And we'll be able to get started. I'm Jennifer Cabrera, and I'm here today with my partner in crime, Jennifer Bell, and we are a part of Karen Zupko and Associates. Today, we're going to be talking about fracture care, which is a pretty hefty topic to review. And so if we have additional time, we'll go into more in-office procedures as well for foot and ankle. But our main focus today is going to be fracture care. Hopefully, you've already reviewed your handout or printed your handout. You see there's a lot of information in here. So bear with us as we get through it today. Okay. All right. And Jennifer is going to be helping me with my slides today. So next slide, please. Okay, well, we may be having a little bit more technical difficulties than I can see is I cannot see your slides at the moment, but we're just going to get started. So we're going to start off discussing a few different changes in fracture care. So obviously, there's some guideline changes and just some text or clarification that has been added in this year and in 2022. So we'll touch on those 2022 changes as well as the 2023 changes. So in terms of coding for fractures, they're typically organized in three different types. So we have our open treatment fractures, our closed treatment fracture care, and then our percutaneous treatment codes. And thank you. We've got our first slide here with anatomy and terminology. Just always a reminder for the practitioners who are on the call today to remember that the anatomy and terminology is the key. So when your coders and fillers are looking at your operative reports and looking at your progress notes, it's very necessary to be as specific as possible when you're speaking about anatomy as it will change the coding options for these. We'll take next slide. Moving on to fracture care, we'll talk about our closed treatments first. And these were updated in 2022, just some definitions where it's defining a closed treatment where the treatment site is not surgically open, meaning you're not visualizing bones. So there's no exposed, there's no bone being exposed to external environment. Now remember, these are organized or described by whether they are with manipulation or without manipulation. So without manipulation is maybe, you know, the bones are in alignment. So you're just going to utilize some form of casting or splinting versus actual manipulation. Now in 2023, CPT revised this definition. You can see that at the bottom of your screen here, and in the middle of your workbook page, that manipulation is now considered reduction by the application of manually applied forces or traction to achieve a satisfactory alignment of the fracture or dislocation. So it's just a little bit of definition change in how they describe what is manipulation. Okay. We'll take next slide. And here's some fracture definitions per CPT and just some examples of that. You'll see we've got our metatarsals there at the bottom and our phalanges. You'll see the closed treatment without manipulation codes versus closed treatment with manipulation codes. I'll take next slide. Now, restorative treatment is a part of the new definition where they want to say restorative treatment is more than simply just realigning of the limb or the fracture. It actually entails that closed reduction by application manual forces. Remember that manipulation, we have to have manually applied forces in order to obtain satisfactory alignment. And if you would like, you can see a tip there in your book and go ahead and read that at your own leisure as far as coding for closed treatments of fractures. It's an excellent article. All right. So just to touch on this a little bit more, and then we'll move into our fracture care and how we build for that is for one example, there is a scenario in CPT assistant in November 2019, where you've got a patient who fell off a ladder and is sustained a fracture. Now in the ER, the ED physician applies a short arm splint and instructs the patient to follow up. So there's been a lot of questions as far as, well, how do you code that for the emergency department physician services for patient A? So I just want to start with those two questions. Again, we're talking about is an actual manipulation done or restorative treatment? So has the physician performed that and will that physician assume subsequent fracture care during the global period? If both of those questions answers are no, then you would just use your CPT code for applying application of a short arm splint is reported by that ED physician. Okay. All right. Let's take next slide. And next slide, please. So it's important that you review some of these things. We are going to skip a few slides today, but remember everything that is in your workbook, you can review it as well. It's very detailed. We just want to try and stay on pace for our hour today. So one of the most common questions we get is, well, how do you handle fracture management when it's a closed fracture that doesn't necessarily need or require any manipulation? Remember manipulated and open fractures only allow for what's called global period, excuse me, global billing methods. Whereas when you have a fracture that is not being manipulated, you now have two billing options. So you can do either an itemized billing option where there's no global period or the alternative method or historical method is the global billing method, which has that 90 day global period. Next slide. So, and this is just a nice little schematic that shows the difference between the two in an itemized method. You're going to have the global fracture code. They're not reported. And the patient does not enter into a 90 day global period. Instead, you would still code for your E&M services and cast applications and cast supplies as itemized billing. Whereas our global method, you would use our global fracture code. And that involves a global period being involved, obviously. Remember with the global period, the first cast or splint application is not billed separately as it's included in that global fracture code. And then subsequent, you know, recasting or reapplications are reportable when medically necessary. And you would end up using that modifier 58 during that global period. So let's visit an example of this on our next slide. Example one, we've got a patient seen in the ER after a fall from a ladder, they've sustained a wrist fracture. The ER physician applies a short leg splint and instructs the patient to follow up with Dr. Ortho in one week. One week later, the patient presents to the office and Dr. Ortho takes and reviews new x-rays and documents the exam of the patient. Now here the cast is applied. Now we're going to talk about what two options does Dr. Ortho have for reporting these services a week after the original injury. We'll see on our left hand side, we've got our option one for the itemized option. Again, you can bill for an E&M visit and that modifier 25 that is there is to establish that you're doing a cast application. And that's considered a minor procedure. So you would want to put that modifier 25 to your E&M code. You also get to bill for the cast application. And then x-rays and cast supplies may vary by place of service. And that typically comes for if you don't have a cost of having to supply those cast supplies or take those x-rays, if you don't own the cost of that, then you cannot bill for it. Okay. Now option two, if you choose global billing method on that return visit, you would be able to bill a, excuse me, I think we're on our next slide. Can we go back one slide? Thank you. We would bill an E&M code with a modifier 57. Now the modifier 57 is because this person is in their 90 day global period. And then the primary code you would actually use is your global fracture code. Okay. So this does not include, you know, we don't believe that the global fracture code does include the work of actually diagnosing a fracture, reviewing it. So you can still get E&M credit for medical decision-making with global billing, as long as your documentation supports that. Now, if we go to the next slide is an extension of this example. And the change really happens when the patient comes in for that follow-up care. So now you've got a patient who has arguments seen by Dr. Ortho, and then they returned to a scheduled visit and their cast is loose. And so we're going to remove that cast. You're going to examine that patient again, obtain new x-rays if necessary, and then place a new cast. So now in this scenario, you still have both options. You've got your option one of itemized billing with potentially reporting that E&M code. Now the modifier 25 is there historically, you know, it was very difficult when you were seeing a patient back for just a cast change or whatnot to establish the history and exam in order to justify a billable CPT code. But now we're using medical decision-making and again, reassessment of a fracture, looking at new x-rays, discussing the healing status of that fracture, all play into your medical decision-making. So it does, you know, support the use of an E&M with a modifier modifier 25. Now, if you chose global billing for the patient initially under the global period, this patient would come in under what's called a post-op visit. So we would choose the post-op visit code for there. So you would not get E&M code billing on this follow-up visit if you chose global billing at the initial, and you still do get the cast application with that protective modifier 58 as well. And then again, x-rays and cost of supplies. All right, we can get next slide. So moving into our open fractures, we've got open treatments. Again, these were updated in 2022, and it was just more clarifying the actual definition of what's open versus closed. And this is treatment. Oh, excuse me. The site is open surgically to expose the fracture to the external environment or is treated through the traumatic wound or extension thereof. So if you have an open fracture that was, you know, patient suffered a traumatic fracture that caused the bone to break through the skin, that's considered an open treatment, even though a surgical incision was not made to open that part of the wound. So, and this can be treatment through an intramedullary nail or well, as well as an internal fixation device. Okay. Now remember application of external fixator for stabilization post-procedure can be separately reported or may be separately reported for certain open treatment codes. And we'll go into that a little bit later. So on our next slide, you'll see this just as a nice, again, examples of different open treatments with their codes. We've got open treatments with internal fixation when performed down at the bottom there with our humoral, excuse me, with our metatarsal fractures, treatments with plate and screws, and then treatment with intramedullary implants. Now, the last part of the fracture treatment we're going to talk about is on our next slide, we're going to say for percutaneous treatments. So again, this was updated in 2022 for more defined or clarity around what these terms mean and percutaneous skeletal fixation is treatment is either open nor closed. The fracture fragments are not visualized, but fixation is placed across the fracture site. Typically, these are your cases that you're doing under fluoroscopic guidance or x-ray guidance and the operative suite. And again, remembering that application of that external fixator if necessary for stabilization post-procedure can be separately reported. Now we get a lot of questions. We'll go to our next slide here. You'll see on your workbook page, you've got a nice, again, percutaneous list of, excuse me, a list of percutaneous codes for these treatments. There are several on them. There are some as well. We've got our calcaneus, talus, our tarsal bones and metatarsals, as well as our great toe and phalanges. Now keep in mind, this is not an all-encompassing list, obviously. These are all the ones that we note for percutaneous treatment. So if there is no CPT code for treatment used at a specific site that is not listed, then it's appropriate to use an unlisted code for that anatomic location and you would use the open treatment code for comparison. Okay. We'll take our next slide, please. All right. So now if we're performing procedures where the billing, where we're billing the fracture management and a code that has a 90-day global period, we do have to understand what's included in that global package. And what's reportable or included really depends on the place of service. So there's a nice schematic here for you to take a look at that. So we'll see, as you can see, it's our two different columns here. We've got our office location. Your billers will refer to this as a place of service 11 versus our hospital or ASC location, or for example, a provider-based practice, which is in that right-hand column. And that would be your place of service is 19, 22, or 23. So remember, as we said earlier, our first CAST application, is that separately billable? And the answer is no in the office location and no in our hospital or ASC setting. Remember, the first CAST application is included in our surgical package. Now, remember, this is what we're talking about is our global fracture period. So now when CAST changes happen during the global period, are those reportable? And the answer is yes in the office location. Remember, report your CAST or SIP application code with your modifier. Now, in the hospital or ASC location, you can report it and it is separately reportable. However, it has to be done by a provider. So it has to be done by your MD, your qualified healthcare professional, such as your PA or nurse practitioner or whatnot, in order to get credit for that. Okay? And you still want to apply a modifier there as well to protect that. Now, supplies in the office, those can be billed separately, assuming, again, that there's that cost relationship where the expense is paid by the practice. In the facility, that's usually a little bit less likely as the facility pays for those supplies. So it would not be separately reported by the physician. Same with x-rays. Assuming the practice you own or rent or lease your equipment, interpret those x-rays, then yes, you could bill that supported. And in the hospital setting, no, as again, it's assumed that the hospital will bill the fees for the x-rays or the radiologist, not the Dr. Ortho or MD provider. All right? So now we can go to next slide, please. Earlier I said that, you know, diagnosing the fracture is not included in the global package. So we just want to take a little bit on our next slide and let's look at how that time is valued for closed treatments. So there is, I'm sorry, it looks like we're missing a slide here, but there is a slide in your package that goes over pre-service evaluation times and intra-service times. And really what we're talking about is that the pre-service evaluation time that's been assigned to your closed treatment code, it is meant for the explanation of the procedure to the patient, the risks, the complications and whatnot, but it really doesn't include anything in there about the actual medical decision-making of diagnosing that fracture, deciding on what phase of treatment, excuse me, what phase of healing it is and the treatment plan. Therefore that medical decision-making would justify that E&M reporting service. Okay? All right. So let's go to our next slide here and we're going to do some scenarios. So this will just demonstrate itemized versus global billing. Okay? So we've got a patient seen in the office with a complaint of left ankle pain, tripping and falling on the sidewalk. The orthopedic surgeon evaluates this patient and takes x-rays and diagnoses a closed non-displaced medial malleolus fracture. Now a short-lived fibroblast cast is applied. So now how would this be coded in place of service 11 in the office setting? We'll take our next slide, please. Now, if you're doing an itemized, if you're choosing to do itemized billing for this service, we can go ahead and advance the slide and you would see that you will be able to get credit for E&M service with that modifier 25 because remember that is the application of the cast is considered a minor procedure. You get your application of your cast, casting supplies, and the x-ray fee would go under the global x-ray fee. Now on our next slide, it'll show you the difference of what happens if you're billing under the global fee. And there you would get your E&M service again with that modifier 57. Your primary code would be that global fracture care code. And again, provided that you share in the cost of this, your casting supplies would be included as well. And then your x-ray code would still be a global x-ray code. All right, on our next scenario here, we've got a 16-year-old soccer player is seen by the practice PA for a leg injury. After history and exam and assessment of x-rays, the PA determines that the patient has a closed non-displaced transverse tibial shaft fracture and places the patient in a long leg cast. We should say that five times fast. So again, we want to identify the reportable codes if the PA is using a global billing. So we're going to look at, and this will look just like the doctor's coding of a global fracture. So you've got your E&M service with that modifier 57, again, your global fracture care code and your casting supplies. And then for your x-rays, you've got your, depending on what your payer requires, they may require that the technical component be billed by a physician as opposed to the PA. You may have to separate those out to the professional component with that modifier 26 and technical component of modifier TC. All right, then next, our next exercise here, we've got the patient in the previous scenario is going to return one in one week and is seen by Dr. Sports. Now Dr. Sports takes and reviews and new x-rays with a separate signed report and documents and examination of the patient. Now the CAS is removed and replaced. And so we're gonna go to our next advances slide here. Now, because this was originally built under the global period or the global fracture care. Now at their follow-up member, they're gonna be considered post-op. So you would use that 99024 since that's the second visit after the global fracture code was used, okay? Now you've got your application of your CAS with that defensive modifier 58 with medical necessity being documented for the new application of the CAS. And again, our casting supplies and our global x-ray code. All right, just a few more scenarios. All right, so we've got a patient with a ankle dislocation fracture is seen in the office by the ED, excuse me, in the ER by the ED physician. Dr. Statt calls for the consultation and the resident goes to the emergency department to see the patient. Now the resident examines the patient, reviews the x-rays and determines that a closed reduction is necessary. This, the resident does the reduction without an attending physician present. Now the reduction is adequate and the patient is placed in a brace and instructed to follow up in three days with Dr. Orofel. So on this scenario, what services are reported by the resident in the ER? And the answer is not reportable for anything. Now remember, teaching point here that your resident services are paid through Medicare and pursue Part A of Medicare and that commercial payers are not paying for resident services and only wanna pay for contracted attending services. So remember your residents cannot report, it's not reportable if performed by the resident in the absence of the attending. All right, so now if the resident called the attending and even discussed this case prior to doing the reduction, is the attending able to report anything for the services provided by your resident in the emergency department? And the answer here again is no. So remember a teaching physician on our next slide must be physically present for the key portion of the service being rendered or for the entire service of a minor procedure in order for it to be reported by the teaching physician. A phone call unfortunately does not count as being physically present. So, all right, let's go to our next exercise. We've got a patient who sees Dr. Orofel three days later, x-rays are taken and reviewed. The fracture is in good position for healing. The detailed evaluation of the patient application of the cath and review the x-ray images taken on the hospital-owned machine are all well-documented. Now images will be read in an official report issued by the hospital radiologist. So now in this scenario, what services are reported by Dr. Orofel for her visit? And here we believe that you would be able to get credit for that E&M service with a modifier 25, application of caths. And again, the x-rays are not reportable part of the MDM, okay? Now supplies here, just of note, are only reportable member if in the place of service 11 and there's a cost to the provider. In this scenario, if it's a place of service 22, like your outpatient hospital or off-campus outpatient hospital setting, there's a cost to the facility, the facility would go for those supplies. All right, our next slide, if the patient did not need a reduction and the resident instead placed the patient in a splint and directed the patient to follow up with the attending physician in the office within one week, could the attending use either the global or itemized methods when seeing the patient? And the answer is yes. So you would still have that option in that follow-up for the attending to use global or itemized options for seeing this patient, okay? All right, and I believe this is our last scenario here. And this one is more specific to what happens if you do an eval on one day and then patient actually has surgery the following day. So we've got a patient that presents to the emergency room with a closed, displaced medial malleolus fracture and Dr. Ortho is called in to evaluate the problem. Dr. Ortho goes to the ER and reviews the x-rays, evaluates the fracture and discusses the patient's ability to undergo definitive surgery under general anesthesia, risks of the surgery are discussed with the patient and informed consent is obtained. Now today, a long leg splint is actually applied by Dr. Ortho and the patient is taken to surgery the following day for an open reduction internal fixation. So now we're gonna look at what we would code on day one versus day two for this scenario. So for day one, the codes that we would potentially use would be our E&M service. Remember, we've got our modifiers 57 and 25. The 25 is protecting your same day splint application and that modifier 57 is protecting your E&M today as you're gonna be going to the operating room tomorrow. We've got our application of splint as well. And then remember that last part, that x-ray component is not reportable part of medical decision-making. Now on day two, the CPT codes may change a little bit where we would say we were not able to report an E&M service. You would have your global fracture care code being used. And again, those x-rays are still not reportable in this scenario. Okay. So moving forward a little bit, there are some NCCI edits that took place in 2023 between NCCI and fractures. There's a lot of texts on these pages in your workbook just kind of showing you how this policy really evolved. So the 2023 initiated in 2014 and has subsequently been changed throughout the years. Most recently in 2023, the version basically read as, now if there's a single cast that's being used to treat multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported. So there's a nice little graph here, excuse me, graph table here to describe that. So if you're treating with a single cast, strapping or splinting or no cast, what we wanna look at is our procedure to procedure edits here. So you've got a procedure one where you've got those closed fracture dislocation without manipulation. And then we're looking at that column two code, say there's another bone within the vicinity that's a closed fracture without manipulation. Now CPT rules define these codes by each bone. There's a CPT code for metatarsal versus the calcaneus or whatnot. So what Medicare had said or NCCI has said, well, essentially if you're putting on a cast or a splint or whatnot that establishes or does the work for both of those fractures, then you should only really essentially be able to report one of them because you're not doing any additional work for that. It's being the additional work for procedure two is being handled in the process of treating procedure one. So in these scenarios, you'll see with some of these codes that when you're treating a closed fracture without manipulation in procedure one and procedure two, you're only still gonna be able to report that procedure one code for Medicare guidelines. Same scenario goes that if you're doing a closed fracture with manipulation or an open or precutaneous treatment of a fracture at the same time as performing a closed fracture without manipulation, you'd still only be able to report procedure one. So and all is that a provider may only report one unit of service for the CPT codes describing that closed treatment of fractures or multiple similar bones is the way the wording is. So example, if a cast is applied without manipulation to say to treat multiple metatarsal fractures of the same foot at the same time, then only one unit of service for that CPT code may be reported. You're not gonna report multiple CPT codes for multiple metatarsal fractures. Okay. All right. So let's move on here. We're gonna talk about some external fixation. This is an area we get quite a bit of questions and there's been some updates to the guidelines. So we'll go over that shortly. If you want, go ahead and take the next slide. We're gonna review some codes in a little bit more detail. We've got our 20690 and 20692 with the definitions of uniplane and multiplane. I'll touch on shortly. Note on this page, you'll see, remember when you're removing an external fixator, there's some codes here that require both in the removal and application, the use of anesthesia. So remember, if the code says under anesthesia, that's not just considered local, it has to be done under actual anesthesia, okay? All right. So there's some documentation tips on our next slide here that go over a little bit more. Application or removal of external fixation during the same operative session or distraction only is not separately reportable. However, external fixators that are removed or adjusted in the office are reportable using CPT code 99024, if removed or adjusted during that global period, or you can use an E&M code if outside of the global period, okay? And then our next slide, just revision or removal of external fixators is performed you would append of modifier 58. Now, what we're seeing here is the changes to the definitions or the definition updates that took place in 2022. Again, this was more just to describe in the use of external fixation, the difference between a uniplanar and a multiplanar XFIX. So you've got your uniplanar. In general, external fixation, obviously the use of pins and or wires that penetrate the bone and interconnected vices for fracture treatment. A uniplanar external fixator places all the pins in approximately the same plane, but may also use a triangular fixation across the joint. And this is in a difference to our multiplanar external fixation that uses transosseous wires and threaded pins. And these are placed in several different planes that are held together with an interconnected stabilizing or tension rings, if you will. So just a little bit of definition changes there or just clarifications, if you will. All right, on our next slide here, again, these are most of our open treatment fracture dislocation CPT codes are defined to include internal fixation only when performed. There are some exclusions that do exist and of note, one of them does take place in the ankle. You'll see our 27848, that top code in our table there where open treatment of ankle dislocation with or without percutaneous skeletal fixation with repair or internal or external fixation. So again, you're not gonna report a separate external fixation code with this code as it's already included in the description that XFIX is included. All right, so moving on to hardware removal, we've got just a little bit again of more clarification or some changes that came about in 2022 and 2023. So essentially AOS revised its advice on this and was trying to give us a little bit more of clarification. So you've got our 20670, which is our superficial removal and then our more commonly used removal code 20680 for removal implant that is deep. As you'll see, there's some shared examples in both the superficial and deep definitions where they're both use a term of a buried wire or a pin or a rod. So assuming the challenge is really deciding when you can report more than one unit of these. So just for clarification sake, for example, our top box there, we've got removal of superficial screws from a healed fracture. We believe this is superficial, so it'd be billed as one unit and CPT and CMS would agree with that. Now, as you move down a little bit, the next one here is that even though we have a bimalleal or ankle fracture, we would consider this deep, but only one unit would be used if you're only removing your plate from the fibula and not the entirety of it through two different incisions. On our next slide, there is, it talks about a both bone forearm fracture, but again, the same thing goes with if we're removing, you know, tibial plateau or tibial shaft fracture fixations. If you're using it from multiple incisions, multiple plates being removed, you would use that deep code. All right. Now, remember that AOS and CPT Medicare does not allow for in-office. So this patient does need to be taken in order to do a pin removal, needs to be taken into a surgical suite. All right. Okay, moving on. Let's talk about our little bit debridement and wound care management codes. So we call these, I like to refer to these as our 10, 11, 12 codes. So these are used typically with our open fracture or dislocations or, you know, traumatically open wounds or whatnot. Again, these are based on the depth of the tissue. So if you can see, we've got our skin in sub-Q for our 10 code, our 11 code is a little bit deeper for fascia and muscle and our 12 code being to bone. So there's no particular size requirement for these. It's reported based on the fracture site and based on the debridement of the depth of the tissue. So remembering your notes here to help your billers and your coders on the backend of this is really need to see the note, the discussion of, you know, excisional debridement, you know, just saying that, you know, you washed out and debrided is, doesn't really qualify and give us that information. So you want to talk about more specifically what was debrided, the depth of it and any excisional debridement being done. Okay. And you have a few different tables on in your workbook of this. We can go to the next slide here. We've got more of our sub-Q codes. This is for more of your wound debridement codes that are not associated with fractures. So the 10, 11, 12s that we talked about earlier was debridement codes with open fractures versus the 1100, 42 codes, 45, 43 that are not associated with fractures. And again, those are all based on depth where it'll specify in the code about subcutaneous versus muscle or fascia and then all the way down to bone. All right. So now with that, if we can go back to that slide just real quick. So a couple of tables that'll be differentiate between your open fractures. Thank you. Open fracture treatment versus non-fracture versus your active wound management. This is a nice little table that kind of sums all that up. Now, remember with your wound debridement codes that you would add the multiple wounds of the same depth. So for example, you would never see multiple units of that 11042 code or 11043. Instead you would see 11042 and then cumulatively you would add up the tissue and say, okay, now we've got multiple units of 11045, okay, as an add-on code. All right. We'll go to our next slide. And this is just more on that same table on how to choose a code, looking at the depth of debridement and whatnot. There's a lot of documentation tips on the next slides or the next pages in your workbook that you're gonna be able to read at your leisure. But just so you know that all that documentation is in there and recommendations on how to document those levels of debridement. So what are you removing foreign material? What you're using to remove the tissue and the depth of the tissue that is removed. So make sure you review that at your convenience. Okay. All right. Next, we're gonna just touch on this really quickly, our negative pressure wound therapies. Just a couple of things of notes and changes that took place. So beginning in 2021, AOS Global Service Data Guidelines, our GSC, revised these codes to say that they were not included with other musculoskeletal services. So that means when they're not included, they can be billed separately or separately reportable, even if it's a part of a surgical procedure. So for example, you've got two different codes here to describe the same type of thing. You've got a negative pressure wound therapy using durable medical equipment. So what that means would be like our wound vacs that we use, you know, your Pravinas or whatnot. As you can see over on the right-hand column, those RVUs, we've got, you know, 2023 RVUs for the facility and the work RVUs are pretty minimal. However, don't knock the small numbers. They definitely add up quickly, especially if you're doing high volume in a foot and ankle practice. So remember, you can get credit for using a wound vac on these surgeries. Again, this is based on size. Now you've got your less than or equal to 50 square centimeters, and then the 97606 code would be greater than 50 square centimeters. Now on our next slide over, we've got 99607, so a little bit different than our 605, where you're using DME. This one is where you're utilizing disposable, non-durable medical equipment. So this would be like your incisional wound vac that you would use or whatnot, as opposed to like a Pravina or whatnot that's a usable, durable medical equipment. So again, these are based on size and making sure you're documenting those sizes. All right, and these are just some examples, but you still have to watch for those procedure-procedure edits, making sure you're always aware of those. But typically, per AOS and CPT guidelines in 2021, that these can be used in conjunction with both closed and open wounds, even in the mix of a surgical procedure, okay? All right. Now I'm going to move on to our drug delivery updates. For 2023, and just shift a little bit here. So in your workbook, again, you've got a lot of different tables and codes and whatnot. And really, this is just discussing the revisions to drug delivery devices and coding that took place in 2023. And specifically, we're talking about the manual prepping of drug delivery devices of note. These are not limited to just arthroplasty. So you've got that mixing and preparation of antibiotics, either therapeutic agents by the physician or your other qualified healthcare professional during a surgical procedure. Now these may be used with any open procedure code except that those that are include the placement of a spacer in the actual definition of the code. So the add-on codes may be used when infection is present, suspected, or even anticipated. And again, looking at that table that you're provided, it talks about the depth of what you're doing these things. So there's intramuscular, there's intramedullary devices, and then there's intraarticular as well in the joint. Okay, we'll go to our next slide. Now for infection that's not being eradicated, you can use those debridement tissue codes that we just discussed. If you're doing a subsequent new delivery device being placed, you have an additional code, the 20700 that can be reported. And then if the infection has been eradicated and you're doing a removal, the drug delivery device removal is the only procedure being performed, you would use that removal of hardware, that deep code 20680. Now keep in mind that your 20704 may not be reported as the placement of spacer is included in the code. So remember, there are some codes where it says removal of hardware and placement of antibiotic spacers, you can't double code or report that twice. Okay. So there's a challenge, the challenge with the drug delivery device revisions right now is that there's a lot of, you know, use with this, don't use with this. So this change really hopefully override that. So if you're coding, if the code you're using doesn't mention a spacer, and you're documenting your work appropriately, you should be able to report those codes in conjunction with each other. All right, and I'll take next slide. There we go. So what's truly different in 2023? Well, new codes were created in 2020. For the insertion or removal of these drug delivery devices, the change should place where the new codes are both reportable for both biodegradable and non biodegradable drug delivery implants. These can be used instead of those debridement code we test for those musculoskeletal applications. All right. And then just a few guideline changes on replantation. So the guidelines for replantation basically have changed slightly, or they've been updated and simplified, and they direct their provider to use that modifier 51 or 59 when they need it, we give you a complete list of those replantation codes for you to use. Again, there's some for the foot after complete amputation. So I just want to make sure you take a look at those. All right. We are making great progress, everybody. I know it's a little fast today. But going back to starting our go back to slide, please. Alright, so we're talking about our radiology. Now we're going to say there's, you know, a lot of very straightforward, you know, topics within radiology, but the questions definitely arise, and they usually arise out of questions about documentation and what needs to be documented or whatnot. So in your workbook, there is a recap and go to the next slide, please, where you've got both member your technical component, and your professional component member global, the term global in terms of x ray refers to billing both the technical and the professional. It's not anything to do with surgical, the surgical global period or whatnot, it's in its own right. So remember, if you're only delivering the professional component, you'll addend that modifier 26 year billing that indicates that the physician is billing that professional interpretation of the radiology versus the technical component that indicates the physician is billing that technical component of the radiology service. So the technical component of that global x ray service reimburses at a higher rate, just so you're aware, example, this would be a setting where the outside radiologist does the readings for you, where they would build that professional component, and you would build a technical component. Okay, let's do our example here, when a patient brings x rays of the knee to the office and the surgeon reviews those films, how should that service be reported, and is not reportable separately as a part of the medical decision making. And then moving on to our documentation is what documentation is really preferable here. So we've got on the right hand side, you know, you've got your basic x ray note here to use the right risk of pure normal versus our recommendation that you would want to use the on type B over here is a separate report. And you always want to don't obviously dictate your laterality, the site, the number of views, and then your findings in more detail. So be as, you know, as comprehensive as you can stating the views that you saw, do they show degenerative changes or whatnot, and make sure it's very clear, we do recommend so that the that the radiology is reported on a separate report and is signed. However, a lot of people do embed this into their note, as long as it's robust. That's okay, as well, you just want to make sure again, that you are actually dictating it as a interpretation, noting your the body part of the number of views and really documenting those findings. Well. All right, our next slide here. Thank you to Jen Bell for helping out. So with our radiology report, again, just to drive this home that separate report, you're going to want to always include your anatomic site, the laterality, your specific views, obviously the results and then sign that that's considered best practice from CPT 2022. And it's just the standard that we also recommend. Okay. Now, is this a requirement for Medicare for patients only not for Medicare patients only? No, we recommend the same reporting style for radiology for all payers. Now, if there's anyone who's listening in today who is not using CR, excuse me, not using digital imaging, there are some modifiers that have to be used for CR imaging or non non digital imaging, we've got our modifier FY, which would be used for any type of CR commuted to the computer radiography images. Now, mind you, in an effort to move people into the digital era, Medicare is applying reductions to these codes, starting in what they start in 2022. It's increasing in 2023 to 10%. So really get on board with digital imaging would be the recommendation. Again, if you're using plain film X ray, the reduction is going to be moved to 20%. And you would modify use a modifier FX for these types of procedures. So all right, and it's just showing you an example of what that would look like. All right. Moving on to our injection coding. Just some brief overview of this for you. We'll take our next slide, you have a nice little graph here as well or a table that it just shows the different the different body parts of different size joints. Remember, we've got codes to do just by with the out ultrasound guidance and then codes that include ultrasound guidance, as well. So you want to make sure you definitely distinguish the use of those codes. We've got our small joints, more of our fingers and toes, our ankles are the intermediate joint and obviously our larger joints are major joints of your shoulders, hips, knees and versus remember that previous years, people are reporting the code 76942 for ultrasound guidance for needle placement. Remember, those are included in the ultrasound guided codes that you'll see the 2060406 and 11 on the right hand side. So make sure you're not reporting those. Now fluoroscopic CT or MRI guidance is performed, you're going to want to see your 77002012 and 021 codes for those. Now payers may definitely scrutinize or question the medical necessity of ultrasound or guidance. So just make sure it's clear in your dictation, and your documentation on why ultrasound guidance is necessary for a foot and ankle injection or whatnot, you know, patient is obese or difficult injection site or whatever the case may be, just really make sure that your documentation supports the use of that. All right, we'll go to our next slide. There's some common injections, obviously, there's some tables in your workbook, that just go over the different types of injections, again, making sure that you're very clear on what you're actually injecting, injecting both in your documentation, as well as your reporting, whether it's a tendon sheath, or you're going into a tendon origin or insertion. If you're doing PRP, CPT has said that you're not going to report the CPT code such as your 20605 or 20550 as your tendon and joint injection codes with a PRP code, that's that 0232T code. Remember that those are not reportable those injections, right? That's a standalone, it's included as well as imaging is assumed included with that injection as well. And that can be seen in the table in your workbook under common office injections. Now, for CPT, you want to always see these questions that we break down CPT versus our global service data is where and what is the physician injecting? Is it documented when reporting for these multiple sites? How many units do you use or compare to the code description? Does it use or include or exclude ultrasound guidance? And remember, you've got those set of codes that includes it so you don't want to code inappropriately there. And now our next we're going to move on to, I'm sorry, going back to injections, there hasn't been any changes from past years on the NCCI guidelines or coding guidelines for this. So just remembering that also you can only report one unit of service for a joint injection of any joint regardless of whether or not you're using it to aspirate or inject at the same time. So the old adage, you know, needle out, needle in, needle out, needle in, if it's in the same body part, and it's within the same vicinity, or it's the bursa of the joint that you were injecting initially, you can only get one unit of service for that injection. All right, moving ahead. Again, I know we're going fast today, but I appreciate you guys sticking with us here. Now we're looking for our foreign body removals at this point. And again, not a whole lot of changes here. There's definitely been some guideline changes in terms of definition of foreign body. So if you've got an implant that has moved from its original position, or structurally broken and no longer serves intended purposes or presents a hazard to the patient, it would qualify as a foreign body for coding purposes. Now what's different about this, the guideline creates various options for reporting or removal of an implant that is moved, broken, no longer serves its body, excuse me, no longer serves its purpose by stating the device is then classified as a foreign body for coding purposes. So the appropriate code for this would actually depend on your procedure location and the foreign body code options for that site. All right, I'll take next slide. All right, so examples of these, you'll see these are all the CPT coding instructions. So these are arthroplasty and prosthesis removal codes. You've got several of those. And on the next slide here, again, we've got another set of codes of examples of coding with foreign body in the procedure description. So you've got your incision or removal form body from subq removal form foreign body from this, you've got arthrotomy with removing foreign body. So there's a lot of different codes that say the same thing. And we show you those codes in your workbook as well. Take this to the next slide. So essentially, if you look at a scenario where you're removing a broken plate in a heel tibia shaft fracture using using open technique, the plate is not within the ankle joint. So you've got all these different scenarios. So it's not an incision and a removal of foreign body from subq. It's not a removal of the foreign body in a muscle or a tendon sheath. And it's not a removal foreign body deep in the thigh region or an arthrotomy of the ankle joint. So in this example, again, we're going all the way back to that original 20680 removal. So just a little bit of clarifications there. Alright, so we do have a few minutes. So we can definitely open up to questions here. I know that was a lot of material all at once. But I'm glad we were able to get through it. We thank you for your time and your questions. And I will turn it over to Jen Bell to see if we have any of those questions that we can review for you. All right. Let's see here. I Yeah, okay. So let's go back if we could. I'd like to go back, Jen, to the radiology separate report, because there's a question here about the does the report, I want to clarify something that I think might have slipped by does the report need to be a when you are billing for the professional interpretation, we want to make sure that everyone understands that's different than, than being able to include it in your note when you're doing an independent interpretation. So if you are billing for that professional interpretation, then you do need to have a separate radiology report. If you're doing the independent interpretation, then that can be included in your office visit for that day. But that separate report does, if you're billing for that professional interpretation as the getting credit for that, which of course means then you couldn't get credit for E&M. So I just wanted to wanted to go back to that because there was a question about that. And we have another question here. Forgive me, I'm going to make this a little bit bigger. Back to the hardware removal topic. If I remove a superficial screw on the medial ankle, but then open incision and removal of a plate on the lateral side, in a separate incision, can I bill both 27680 and 27670? Jen, do you want to take this one? Or do you want me to take this one? You go ahead. Thank you. The answer is yes, you can. You'll want to apply because those will hit up against edits for each other. And since we don't have left and right on the laterality of one single ankle, then you would want to apply that modifier 59 to the lesser code. Because modifier 59 is a monetary modifier, so it's going to decrease the payment. So we always want to put that on the lesser of the two codes. So yes, you can bill 27680 and 27670 with that modifier 59, as long as you document appropriately. Thank you, Dr. Drew for that, for that question. Yeah, and Dr. Drew, just to clarify, those codes are 20670, 20680. So just the numbers got switched around a little bit there. But the 20670, 20680. Yes, yeah. That's my pleasure. Let's see. Also, are there any codes for repair of syndesmosis is bundled with? Um, we'd have to see that we'd have to see what was performed in the op report. We'd need a little bit more information on that, I think. For sure on that. And Jen, did you do you want to speak to that question? Also, are there any codes for repair of syndesmosis is bundled with that's kind of a kind of an Yeah, I'm not. Yeah. And off the top of my head, I'm not, I'm not sure I would have to look into it, like you said, a little bit more, and see specifically what you know what the scenario entails, what else is being Yeah, what was actually done. But we'd be happy to look, look at that for you. We'd need that, you know, because that would be a separate, separate thing. But we'd be more than happy to look at that for you. If you'd like to contact us at the information at Karen zupko.com. Okay. All right. Okay. I think that may be all of our questions. Are you seeing any more come in here? I do have one. Again, Dr. Drew gave us a little more information. So as I've been told that when using the code for or if distal tibia and fibula, that is syndesmosis code could not be used and bundled together. I believe that is accurate. Again, we would want to see that. I want to see how it's documented to see exactly what was done. But yes, typically, that would be handled. Yeah, and that scenario definitely would be so awesome. And anyone else have any more questions? Jen Cabrera deserves a gold star today. Use her phone for zoom. So thank you for the technical difficulties that we had. I think that's it. I'll let you say last words. Thank you, everyone. Please take a look. Again, there's a lot of resource and a lot of information in your book. We definitely touched on everything today. But for a little bit more detail, take a look at that handout. And we welcome any additional questions or any feedback that you have. Thanks for bearing with us with some technical difficulties today. But I hope you found the session informative and enjoyable. So thank you. Have a great rest of your day. Thank you.

fracture care

foot and ankle

coding guidelines

documentation requirements

billing options

percutaneous treatments

radiology reports

foreign body removals

comprehensive guide