An Orthopaedic Surgeon's Guide to Billing and Coding

Abstract

Understanding the nuances of musculoskeletal documentation, coding, and billing is an integral part of any orthopaedic practice, but these nuances are not actively taught in most orthopaedic residency programs. The paucity of medical billing education overwhelms many young orthopaedic surgeons as they begin their first job. In addition, not understanding how their value as a surgeon is calculated poses a significant disadvantage when negotiating employment contracts. The purpose of this review article is to educate orthopaedic residents, fellows, and new attendings on how to effectively document during clinical and surgical encounters to maximize value, understand basic orthopaedic coding, and introduce important billing concepts. Proper documentation, coding, and billing are an integral part of an orthopaedic practice, yet few orthopaedic residency programs incorporate any formal training or didactics on these topics. 1 As orthopaedic trainees enter the workforce, understanding reimbursement models is crucial to both financial success and job satisfaction. 2 Furthermore, the interplay between coding, billing, and the relative value unit (RVU) system is extremely important because it governs much of the financial structures and incentives within a medical practice. In some workplace settings, it is a proxy for surgeon productivity and can be an area of contention when negotiating employment contracts.Coding is the process of assigning appropriate alphanumeric codes that are standardized across the healthcare industry. Large financial penalties can result if coding is performed incorrectly. Billing is the process by which a provider is paid for their services from both the insurance carrier and the patient. The terminology for coding and billing is very specific, with many definitions and an alphabet soup of acronyms that may be unfamiliar to the newly practicing physician (Table 1).Physician reimbursement is based on rules established by the Centers for Medicare and Medicaid Services (CMS) and can be simplified into a three-step process beginning with assigning the appropriate service code using the Current Procedural Terminology (CPT) database. Next, an International Classification of Diseases (ICD) diagnosis code is paired with the procedure code. Finally, the CMS Resource-Based Relative Value Scale is used to