The Orthopaedic Coding Coach 2006 Archives

Question:

I was recently told by another office that if a patient brings in their films and my orthopaedic physician reads them even though there is a printed reading that we can bill for that interpretation. Can we bill 73564-26 for re-reading those films?

Answer:

No, the review of the x-rays during the physicians office visit is included in the data review section of the Medical Decision Making component of the E&M visit. Since the x-rays have already been interpreted, your physicians review is not separately billable as a separate interpretation.

Question:

Our physicians have a question about how to report an E&M service when the patient is unconscious and they cannot obtain a full history. Since consults and hospital admission codes require documentation of 3 out of 3 key components, how do we handle the history if the patient is unconscious?

Answer:

Good question and hopefully this is a situation that is an infrequent occurrence.

According to the AMA CPT Guidelines, the physician in this situation is given “credit” for a comprehensive history. The following is an excerpt from the AMA CPT Assistant regarding E&M documentation criteria. You will note in the statement, that this is a combined Medicare (now CMS, formerly HCFA) and AMA position.

On April 27, 1998, the American Medical Association convened the physician leaders and staffs of organized medicine for an open and candid exchange of opinions and concerns with representatives from the Health Care Financing Administration, Health and Human Services Office of the Inspector General, and the CPT Editorial Panel.

In response to physician concerns and vigorous advocacy efforts by the AMA, state medical associations, and medical specialty societies, HCFA officials announced at the meeting that it has agreed to: "Add a clear note that, when a history cannot be obtained due to specific patient conditions (e.g., inability to communicate urgent, emergent situation, etc.), the history is deemed "comprehensive" for coding and documentation purposes."

Question:

Our surgeon saw a trauma patient who had a laceration repair by the ER physician and presented to our office for follow-up care. Our surgeon removed the sutures and wants to know how to report this procedure.

Answer:

Suture removal may only be reported if the sutures are removed in the operating room under anesthesia (other than local), either by the physician who placed the sutures (CPT code 15850) or by a physician other than the surgeon who placed the sutures (CPT code 15851). Sutures removed in the office are either part of the 10 day global period, or in your scenario, part of the E&M service.

Question:

Whenever we use the CPT code 22850 for removal of instrumentation and then a new code for placement of instrumentation at a new level, we are always denied as bundled. Why are we not getting reimbursed?

Answer:

I am not sure why your payors are denying this as a bundled procedure when reporting 22805 or 22852 and then one of the codes 22840, 22842, etc. If this is occurring, append modifier 59 to the lesser valued procedure to indicate the removal and replacement are at different levels. In your appeal letter, inform them you know that if the instrumentation is removed and reinserted at the same levels, the correct code is 22849, but the physician's documentation supports removal at one level and placement of new instrumentation at new levels.

Question:

In our hand therapy department, we bill code 97039 for fluidotherapy. Medicare does not cover this code. Are we coding this correctly when we use the unlisted code or is there a more appropriate CPT code?

Answer:

Good news—you do not have to use the unlisted CPT code. According to the AMA, the correct code is CPT code 97022, Application of a modality to one or more areas; whirlpool.

In the May 1998 CPT Assistant, the AMA advises the following:

Fluidotherapy is actually a dry whirlpool containing crushed corn husks. This dry whirlpool of crushed corn husks increases the circulation by increasing heat in the tissues. It also increases range of motion. The appropriate code to report for fluidotherapy is 97022, Application of a modality to one or more areas; whirlpool.

Question:

Is there someplace I can obtain a list of procedures that are appropriate to bill for surgical assistants?

Answer:

Absolutely! Look in the RVU section of the AAOS’s Code-X product. For each CPT code, you will find the rules that define when Medicare will reimburse for an Assistant Surgeon (MD, DO) or NPP (PA, NP, CNS) to assist at surgery. This information is also available in the Medicare fee schedule. Medicare does not reimburse for surgical assistants who are not MD’s, DO’s, PA’s, NP’s, or CNS’s .

Basically, in order to report an MD, DO PA, NP, CNS as an Assistant Surgeon (MD/ DO), or an Assistant at Surgery (PA, NP, CNS) the primary surgeon must document the medical necessity of the Assistant Surgeon or Assistant at Surgery and dictate the Assistant’s role and work performed as the Assistant.

If the primary surgeon does not dictate the role/work of the Assistant, then the Assistant may not report any services for assisting on the surgical procedure.

Whether or not a payor reimburses becomes a payor issue, not a coding issue.

Question:

What codes are billable and payable for vacuum assisted wound closure?

Answer:

If the physician is reporting services for applying or changing the vac assisted wound dressings only, the appropriate codes are:

97605: Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97606: Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

If the physician is performing other surgical procedures at the same time, do not report the wound vac dressing in addition to the surgical procedure.

Question:

What CPT codes may be reported for the application of antiobiotic beads when the physician is treating an infected fracture site?

Answer:

Refer to the series of CPT codes 11981-11983 to choose the appropriate CPT code that reflects the work performed and documented.

CPT code 11981: Insertion, non-biodegradable drug delivery implant

CPT code 11982: Removal, non-biodegradable drug delivery implant

CPT code 11983: Removal with reinsertion, non-biodegradable drug delivery implant

Question:

If the physician performs a partial or total corpectomy, is that segment still counted for fusion/instrumentation?

Answer:

The fusion and instrumentation codes may be reported in addition to the corpectomy. The physician may place a structural allograft to fill the space created by the corpectomy (20931) and may also perform a posterolateral fusion of one or more levels, one of which may be the segment where the corpectomy was performed.

Question:

Can you bill for local bone graft (CPT code 20936) for spinal procedure twice when there one is obtained posterior and one is obtained anterior?

Answer:

No, while you may report more than one bone graft (20930-20938) per operative session, each type of graft (20930-20938) may only be reported one time per operative session.

Question:

We have a new spine physician and are a bit confused about the CPT codes that include the term “segment” in them. We are unsure how to count levels of fusion when he dictates a posterolateral fusion L1-L5. How do I know how to count the number of levels fused?

Answer:

The terminology is a little confusing, so you are right to question exactly how to code these cases. In order to perform a fusion you must have two segments to fuse together. You will note in the definition of CPT code 22612, the code reads, single level, not single segment, “Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)”

In your scenario the physician would code this as follows:

22612 Fusion L1-L2 single level fusion.

22614 Additional segment fusion L2-3 (L3 is the additional segment)

22614 Additional segment fusion L3-4 (L4 is the additional segment)

22614 Additional segment fusion L4-L5 (L5 is the additional segment)

Question:

My surgeon uses intraoperative monitoring for all of his spine surgical cases. How should I code for this monitoring?

Answer:

Intraoperative monitoring is inclusive in the surgical package and should not be coded separately, according to CPT, AAOS, and Medicare.