Orthopedic Coding Alert

By following these expert tips, you can help protect your office against denials.

From overreported level 5 evaluation and management (E/M) visits to outdated note templates, small documentation missteps can create significant coding and compliance concerns. During their HEALTHCON 2026 presentation, “Denial Trends and Resolutions in Orthopedics,” Lynn Anderanin, coding compliance manager and Cheryl Patterson, coding manager, both from EmergeOrtho, brought solutions to many of these problems.

In part 3 of this orthopedic coding series, Anderanin discussed several common trouble spots she encounters in orthopedic practices and shared practical solutions to help coders support their medical staff and their coding decisions, strengthen documentation, and reduce denials.

Understand MDM in Your Ortho Office

Anderanin began by breaking down the medical decision making (MDM) categories as they relate to most orthopedic appointments as follows:

Problems addressed at the encounter:

• Straightforward: Checkup with no issues or a discharge visit
  • Data: Straightforward visits often have no data
  • Risk: None, simply bracing, splinting, or rest suggested
• Low: Active treatment plan or follow-up appointment
  • Data: Two from category 1 or category 2
  • Risk: Injections, over-the-counter (OTC) drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) recommended, physical therapy
• Moderate: Established patient with exacerbation
  • Data: Three from category 1 or category 2 (independent interpretation, documentation), or three from category 3
  • Risk: Prescription drugs for pain management, surgery, social determinants of health (SDOH)
• High: Seriously ill patient
  • Data: Any two or three from the moderate level above
  • Risk: Drug therapy, emergency surgery, hospitalization, etc.

Get All Practitioners on the Same Page

Anderanin explained how sometimes it can be difficult to get all of the practitioners to reach an agreement when it comes to interpreting MDM. For example, one practitioner thought that if they were independently interpreting the X-rays performed in the office that day, they could also factor that into the MDM. She explained to them, “No, because you are already getting paid for [the interpretation] in the X-ray charge, you cannot also get credit in the data.”

She went on to explain how so many of the practitioners she worked with were originally claiming to have up to 15 “level 5s” in a single day, when that would stick out as nearly impossible to any auditor. “Most of the time, if you’re suggesting something is a level 5, this is a patient who’s in the hospital and seriously ill or who has a serious injury,” Anderanin said.

Keep Your Templates Updated

In her spare time, Anderanin performs audits for other medical offices. She mentioned that the most startling thing she’s noticed is that most offices are not updating their templates as the coding guidelines change. “Some offices are still using those same templates from 1995 or 1997. So, you know what that tells me? That they are copying and pasting everything,” she said.

Anderanin went on to discuss how using templates in your office can improve documentation consistency and efficiency, but only when they are kept up to date with changes related to coding guidelines and the needs of patients. Practices should make an effort to review these templates regularly, remove outdated language, and update prompts to reflect these changes. Practitioners must also tailor each note to the patient encounter rather than relying on copied and pasted information that could lead to inaccuracies, audit concerns, or denials.

While templates can promote consistency and efficiency, this is only when they reflect the current coding rules and documentation requirements. Staff education is equally important because practitioners need to understand that templates are tools, not substitutes for documenting the patient’s specific condition, treatment options, or progress. Staff should understand that a well-designed template guides complete documentation without encouraging copy-and-paste habits.

Catch Denials Before They Happen by Performing Pre-Audits

In Anderanin’s office, all of the auditing is done before they send the bill out. “We’re making sure the claims are going out with the correct codes, and no MDM level 5 goes out of our office without a review.” Anderanin performs pre-payment audits of E/M claims, reviewing them for appropriate level selection before submission to payers such as UnitedHealthcare (UHC), Cigna, and Aetna to help prevent denials.

“Whenever something is a little bit of a gray area, put it in your compliance plan,” said Anderanin. “For example, what do you do in your office, how do you interpret it, what are the rules you want everyone to follow, how do you [want them to enforce those rules]?”

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC