Not much has changed with shoulder procedures over the past few years so let’s talk about PRP injections into the rotator cuff and the issue of documentation as it relates to diagnosis coding.
Everyone should be familiar with Category III code 0232T which represents the platelet rich plasma injection. I want to go back to the original CPT Assistant regarding these types of injections and remind you that “the installation of platelets by the surgeon into the surgical site would not warrant additional CPT code reporting because it is considered an integral part of the total procedure performed.” What we were allowed to report was 86999 for drawing and processing of the blood. Since drawing and processing is now included in the Category III code there isn’t a reportable code when PRP is injected into the operative site after a rotator cuff repair.
Report 0232T when a PRP injection is the only service performed, for instance as a treatment for plantar fasciitis of the foot or epicondylitis of the elbow.
ICD-10. It’s getting closer and change doesn’t happen overnight. One fact that can’t be stressed enough is that NOW is the time to start working with your physicians to improve diagnosis documentation. If you haven’t seen the code structure for ICD-10 yet, let me give you an example. Take a fracture at the surgical neck of the humerus. What does a coder need to know? Was this a 1, 2, 3, or 4 part fracture? Was the fracture displaced or nondisplaced? And there is a seventh digit required noting the episode of care (initial encounter, subsequent encounter or sequel). As you can see this is all information which isn’t documented in operative reports at this time. Undocumented conditions will only lead to physician queries and delayed claims submission for your facility.