The Orthopaedic Coding Coach 2008 Archives

Conversion to Open Procedures

Question:

How do we code an arthroscopic rotator cuff that was converted to an open rotator cuff for a chronic tear of the subscapularis and supraspinatus tendons?

Answer: 

The surgeon reports CPT code 23412, Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic.

CMS 1500 Claim Rejection for Incomplete Data

Question:

We recently began receiving rejections from Medicare because we did not have an entry in Box 11 on the CMS 1500 claim form.  Medicare is telling us we must put NONE in the box if there is no primary Insurance.  This has never happened before.

Answer:

We researched this question and found the following instructions in the Medicare Manual.  The Medicare instructions state that if the patient does not have any primary insurance to Medicare, the word “none” must be entered in box 11.  Here is the excerpt form the Claims Submission Instruction section related to the question.

Item 11 -THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER. If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c. Items 4, 6, and 7 must also be completed. NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11. If there is no insurance primary to Medicare, enter the word “NONE” and proceed to item 12.

We believe that although the policy existed before, it was not enforced as zealously as CMS wanted.  Your recent denials are likely due to this fact.

Is 22851 One Time or Per Operative Session or Per Interspace?

Question: 

Can 22851 be reported one time per operative session or for each interbody space?

Answer: 

22851 may be reported per interspace.  It is not uncommon for a surgeon to place cages bilaterally, but you cannot code for bilateral placement.  However, if the surgeon places a cage at 2 separate interspaces, the code may be reported twice – such as 22851 and 22851-59 – to indicate the second interspace.

Question: 

We are unsure when to report CPT code 22851 versus 20931.

Answer: 

CPT code 22851 is used for interbody fusion when the physician documents the places of cages or threaded bone dowels.  CPT code 20931 is used when the physician places an interbody bone allograft that is not a threaded bone dowel, but is a structural allograft.

Question: 

Our new shoulder surgeon performed an arthroscopic biceps tenodesis at the same time as an arthroscopic rotator cuff.  How do we code this?

Answer: 

There is no CPT code in 2007 for the arthroscopic procedure.  Use the unlisted arthroscopic CPT code, 29999.  Base your fee on the open biceps tenodesis, CPT code 23430.

Question:

We are having difficulty getting reimbursed when an assistant surgeon is billed for some procedures like hip replacement or rotator cuff surgery.  The assistant surgeon’s or the assistant at surgery’s name and credentials are listed in the operative note.  Our appeals have been unsuccessful in getting paid.  Any ideas?

Answer: 

First, make sure you are reporting the appropriate modifier.  Modifier 80, 81 and 82 are physician modifiers while Medicare recognizes the AS modifier for the PA, NP, CNS who assists at surgery.  You mention that the Assistant Surgeon or Assistant at Surgery’s name is listed in the operative note.  Does the operative note also include their presence for all or part of the case, work performed as the assistant, and medical necessity.  If only the providers name is listed, the payors may decide that the services are not reportable.   The primary surgeon should dictate the operative note and indicate why the assistant is needed, state the medically necessity for an assistant, whether they were present for all or part of case, and include the work the assistant performed. 

Question:

Our surgeon repaired a fracture using morselized allograft.  He submitted CPT code 20930 for the allograft.  Is this correct?

Answer: 

No, there is no CPT code to report the allograft for the fracture repair as it is not separately reportable.  CPT code 20930 allograft is for spine surgery only; morselized is used for spine cases only as indicated in its definition.