Medical Billing Expert Witness Orthopedics

Finding an expert witness in medical billing orthopedics requires assessing whether the expert understand some of the most frequent procedures that are billed by orthopedic surgeons, and the associated billings that are generally associated with orthopaedic specialty procedures.

As we will show you with some de-identified case examples below, an experienced expert in orthopedic medical billing and medical coding should be adaptable to real-life scenarios with less than perfect information, such as:

• Ambiguity
• Incomplete Documentation
• Procedures listed with no CPT code
• Devices or medications without HCPCS codes

Several elements can challenge experts in creating a transparent and objective analysis.  These include:

1. the varied notations that are utilized in clinical documentation and operative notes,
2. how to determine the coding or code procedures for comparative analysis when they are not listed with the procedure
3. using clinical documentation to illuminate gaps in medical billing and to determine the accuracy of the billing
4. various modalities for surgeon fee comparisons, facility fee comparisons, associated surgical screws or other devices (if applicable) and facility fees
5. diagnostic imaging fees, such as Magnetic Resonance Imaging (MRI) including the technical component (‘tech fee’) and the interpretation by a radiologist or orthopedic surgeon (professional fee or ‘pro fee’)
6. injections for pain may be a component of the billing
7. post surgical physical therapy billing
8. neurosurgical consultations as well as initial patient assessments using evaluation and management (E&M) medical codes (e.g., 99204 for a new patient, 99214 for follow up assessments with existing patients).  The levels of E&M coding (e.g. level 2, level 3, level 4 may need to be considered and whether the medical documentation meets industry standard guidelines)

Checks for appropriate billing that meets industry Standards:

1. duplicate billing of procedures detection
2. detection  inflated billing for facility fees for the surgery center, or more than one facility fee billed in the same day
3. it is important to note that an Ambulatory Surgical Center (ASC) is a specific certification by Medicare.  Not all surgical centers are Ambulatory Surgical Centers.
4. unbundling of medical coding (meaning that at times it is expected that an injection and the fluoroscopic guidance, for example may be included in one code, or there may be situations where a certain type of injection may allow separate billing for guidance)

Insurance coverage determinations

1. in cases where medical necessity is disputed, the commercial insurance, workers compensation or self-insured ERISA plan coverage determination policies should be evaluated.
2. In Medicare cases, the Medicare local coverage determination (or Medicare LCD for short) should be evaluated
3. at times prescribers of controlled substances including drugs as opioids and the policies governing use of opioids may be relevant

Medical liens or Letters of Protection

1. medical liens or hospital liens may be a relevant topic as part of the medical bill review process
2. in certain jurisdictions such as Texas, medical bill review affidavits may be utilized, however if the affidavit is not signed by an individual who can be a testifying expert then such a medical billing expert witness would need to be retained

First orthopedic example for procedures performed by a spine surgeon:

This is a hypothetical example and not an endorsement of correct coding, or criticism of incorrect coding.  These de-identified examples are incomplete as they were presented in personal injury cases.

For example a set of diagnoses and procedures might be:

Preoperative orthopedic diagnoses (which may or may not have the most precise specificity):

1. 1. C6-C7 disc herniation
   2. Cervical stenosis

Procedures:

1. 1. Partial corpectomy of C6
   2. C6-C7 discectomy for decompression
   3. C6-C7 arthrodesis with PEEK graft and morselized bone allograft
   4. C6-C7 anterior cervical instrumentation with plates and screws

• Anesthesia time and units billed separately.
• Surgical center facility fee billed separately
• Surgical devices billed separately

Second orthopedic example for procedures performed by a spine surgeon

This is a hypothetical example and not an endorsement of correct coding, or criticism of incorrect coding.  Any similarity to an actual patient is coincidental.  These de-identified examples are incomplete as they were presented in personal injury cases.

A medical billing expert witness in orthopedics should know how to evaluate a scenario such as this:

Assessment and Plan

1. 1. ICD-10 diagnosis code: Neck pain (M54.2)
   2. ICD-10 diagnosis code: Lumbar disc herniation (M51.26)
   3. ICD-10 diagnosis code: Cervical radiculopathy (M54.12)
   4. ICD-10 diagnosis code: Lumbar back pain (M54.5)
   5. ICD-10 diagnosis code: Annular tear of lumbar disc (M51.36)
   6. ICD-10 diagnosis code: Lumbar facet joint syndrome (M47.816)

PREOPERATIVE DIAGNOSIS:

1. 1. Lumbar radiculopathy
   2. Lumbar pain
   3. Lumbar foramina stenosis
   4. Low back pain (note that these is a non-specific diagnoses)

PROCEDURE LIST:

1. 1. Left L-4 Lumbar Laminotomy (no CPT code(s) listed for the orthopedic procedures – this will need to be coded with a precise code and underlying assumptions for comparative analysis)
   2. Left L5 Foraminotomy.
   3. Interpretation of the MRI of the Lumbar spine intra-operatively.
   4. Interpretation of the X-Ray of the Lumbar spine intra-operatively.
   5. Use of Fluoroscopy intra-operatively.
   6. Use of SSEP and MEP for upper and lower extremities intra-operatively.
   7. L4-5 Discectomy.
   8. Neurolysis.
   9. L4-5 Fat Graft.
   10. Synovial Cyst EXTRA-Spinal Resection.
   11. Epidurogram.
   12. Epidural Block

• Anesthesia time and units billed separately.
• Surgery center facility fee billed separately
• Surgical devices billed separately

Third orthopedic example for procedures performed by a spine surgeon

This is a hypothetical example and not an endorsement of correct coding, or criticism of incorrect coding.

These de-identified examples are incomplete as they were presented in personal injury cases.

An expert witness in medical billing for orthopedics should know how to evaluate a scenario such as this:

1. 20930 Allograft, spine surgery
2. 20936 Autograft, Spine Surgery
3. 22558 Arthrodesis, Anterior interbody fusion
4. 22585 Arthrodesis, Anterior interbody fusion
5. 22845 Anterior instrumentation; 2 to 3 vertebral segments
6. 22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace
7. 64999 Unlisted Procedure, Nervous System
8. 64999 Unlisted Procedure, Nervous System
9. 76000 Fluoroscopy
10. 20930 Allograft, spine surgery
11. 20936 Autograft, Spine Surgery
12. 22612 Arthrodesis, Posterior
13. 22614 Arthrodesis, Posterior
14. 22842 Posterior segmental instrumentation
15. 76000 Fluoroscopy
16. 99080 Form Completion

• Anesthesia time and units billed separately.
• Surgical center facility fee billed separately
• Surgical devices billed separately

Associated MRI billing may appear in medical billing such as this example:

1. 73221 MRI R any joint of upper extremity; without contrast material
2. 72141 MRI Cervical Spine w/o contrast
3. 73221 MRI R any joint of upper extremity; without contrast material
4. 72148 MRI Lumbar Spine w/o contrast

Post surgery physical therapy may include medical codes such as these:

1. 97163 E/M Detailed History/Exam
2. 97110 Therapeutic Procedure
3. 97140 Manual therapy
4. 97014 Electrical Stimulation

Other Orthopedic Billing Expert Witness Competencies
The CPT codes associated with the surgeon’s bill should be well-understood, with any CPT code modifiers (not shown here)

In addition, anesthesia charges are billed separately and are time-based.

The orthopedic screws and other devices are generally described using HCPCs codes and should be compared to a standard set of data in the community

Finally, the facility fee in, for example, an ambulatory surgery center or hospital should be considered.

Comparative data on providers, facility fees and anesthesia fees are generally prepared with an analysis of usual customary and reasonable charges in personal injury cases.  In other types of cases such as insurance disputes with providers, the amount that a health care provider accepts as payment in full is used.

Related Topics

Medical billing expert witness

Ambulatory Surgical Centers

Workers Compensation

Commercial insurance plans

Medicare Local Coverage Determinations