2022 ASC Coding Tips: Improving Orthopedic Clinical Documentation

By Kris Brown, RHIT, CPC, CPMA, CASCC, Senior Coding Manager

Missing information in an operative report is a common cause of billing delays. If the documentation needed for coding is missing or unclear, the coder must initiate a physician query to obtain the information. The tips below, focusing on orthopedics, will help reduce the number of queries required, increase overall compliance, and secure optimal revenue for your ASC.

Wound debridement — Requires documentation of the total square centimeters debrided in addition to the depth of tissue involvement (skin, subcutaneous, fascia/muscle, bone).

Lesion excisions — Soft tissue tumors such as lipomas require documentation of the size of the lesion removed in centimeters and the depth of the tumor (subcutaneous vs. subfascial/submuscular).

• If removed from the limbs, specific location is required (forearm/wrist, upper arm, shoulder, thigh/knee, lower leg/ankle).
• If multiple lesions are removed, document the dimensions and location of each lesion.

Open rotator cuff repairs — The documentation must specify if it is an acute or chronic tear.

• Specify if the tear was caused by an injury or traumatic event as this is considered acute regardless of the amount of time that has passed since the incident.
• Specify if the tear is degenerative in nature. This is usually caused by repetitive use.

Arthroscopic debridement — Document each specific structure debrided and the location of the debridement.

• If rotator cuff is debrided, specify which side (articular and/or bursal).
• If glenoid and humeral cartilage and/or bone is debrided, specify each one instead of “glenohumeral joint debrided.”

Forearm fractures — Specify location (proximal, shaft, or distal).

• If distal ulna, it needs to be specified if it’s the styloid.
• For distal radius, specify extra- vs. intra-articular involvement, document the number of fragments fixated.

Flexor tendon repairs (hand/finger) — Document the zone/location.

• Specify the name of each tendon repaired.

PRP injections — Document the source of the PRP (patient’s blood, off-shelf product, etc.)

Non/malunion — Document the specific type/cause (fracture, previous procedure, etc.)

Avoid eponyms — Document the details of the procedure and all anatomy involved instead of just naming it.

• For example, rather than saying “I then performed a Mumford procedure,” detail the amount of distal clavicle removed in centimeters or millimeters and include the method(s) of removal.
• For Austin/Akin bunionectomies, document the location of any osteotomies.