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The Orthopaedic Coding Coach 2009 Archives
| ACL Reconstruction With Mosaicplasty, Are They Both Reportable? |
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December 17, 2009
Question:
We are getting ready to precertify a surgical procedure and wondering if we can precert an ACL reconstruction and an arthroscopic mosaicplasty? Are they both reportable?
Answer:
Both services may be reportable during the same operative session assuming the medical necessity and documentation supports both procedures.
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| Endoscopic Cubital Tunnel Release |
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December 3, 2009
Question:
Our surgeon gave us an operative note where he documented an endoscopic cubital tunnel surgery. We cannot find any endoscopic procedure codes in the CPT book for this procedure.
Answer:
Report the procedure using an unlisted arthroscopy CPT code, 29999. Use the base code 64718 to set your fee and explain the unlisted procedure to the payor.
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| Procedure Code 20660 and Cervical Spine Procedures |
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November 12, 2009
Procedure Code 20660 and Cervical Spine Procedures
Question:
Is procedure code 20660 bundled into cervical spine procedures? We are receiving denials on 20660 from insurance companies, particularly Medicare, when we bill 20660 with 63075 or 63081.
Answer:
Yes, 20660 (Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)) is included in all spine procedures when fixation such as Gardner-Wells tongs is used throughout the case.
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| Are External Fixator Codes Modifier 51 Exempt? |
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October 29, 2009
Question:
I am having difficulty getting paid 100% on the external fixator codes which are modifier 51 exempt. I have appealed in the past and received the full 100%, but in recent appeals the payor is denying the claim for additional payment. Do you have any suggestions or thoughts on how to appeal?
Answer:
To answer your question let’s look at each code and its payment status.
There are three codes for application of an external fixator: CPT codes 20690, 20692 and 20696; all are subject to a 50% reduction as they are not modifier 51 exempt. The exempt status for CPT codes 20690 and 20692 was removed by CPT in January 2008. CPT code 20696, new in 2009, was not introduced as an exempt code.
Action:
When reporting CPT codes 20690, 20692 or 20696 as a subsequent stand-alone procedure, append modifier 51 as appropriate. The modifier indicates it is subject to the multiple procedure payment formula, unless there is a contractual carve-out for these procedures.
Accept payment at the appropriate multiple procedure payment formula unless there is a contractual carve out.
There is one code for the strut exchange: 20697. CPT code 20697 is modifier 51 exempt thus 100% reimbursement is expected for each strut. The reimbursement is for the cost of the struts and has no physician work valued into the code, hence it is exempt from modifier 51. CPT code 20697 has 33.09 RVUs, of these 33.08 RVUs are allocated to the practice expense, and 0.01 RVUs are allocated to the malpractice expense.
Action:
When reporting CPT code 20697, do not append modifier 51.
Appeal payments that are less than 100% of the allowable.
Improve your practice’s coding by taking this next step.
Visit www.karenzupko.com to sign up for the AAOS Sponsored Coding and Reimbursement Courses. Topics such as this question are covered in detail and new information is presented each year as coding and reimbursement rules change.
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| Revision Total Knee and Allograft Placement for Bone Cysts |
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October 19, 2009
Question:
Our surgeon performed a revision total knee replacement when she revised the tibial component and liner. In the dictation, she mentions that the patient had a bone cyst on the femur and the tibia which she filled with 30 cc allograft to close the defects.
Can we report the CPT codes for the curettage and allograft in addition to the revision total knee one component?
Answer:
No, per the Global Service Data Guide, “local bone graft and fixation for local bone defects or cysts” is included in CPT code 27486, Revision of total knee arthroplasty, with or without allograft; one component thus allograft is not separately reportable and the curettage of the bone cyst is also included.
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| Internal Fixation and Osteotomy? |
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September 17, 2009
Question:
Our surgeon performed an osteotomy of the ulna and the documentation includes internal fixation. Is the internal fixation inclusive to the osteotomy code.
Answer:
Yes, CPT code 25360 Osteotomy; ulna includes internal fixation as an integral part of the procedure.
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| Metacarpal Fractures, One Code or More? |
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August 20, 2009
Question:
Can we report the treatment of three metacarpal fractures with a three in the units box with CPT code 26600?
Answer:
Yes, it would be appropriate to report 26600, Closed treatment of metacarpal fracture, single; without manipulation, each bone with a three in the units box. However, we do not recommend the use of units in hand cases unless the payor requires units in which you would submit the claim as follows:
| CPT Code |
Units |
Charge |
| 26600 |
3
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Increase fee x 3 |
We prefer and recommend the following format if the payor allows line item posting:
| CPT Code |
Units |
Charge |
| 26600 |
1
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1x |
| 26600-59 |
1
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1x |
| 26600-59 |
1
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1x |
If the payor rejects the third code as a duplicate, the practice will know how to appeal based on the denial reason. It is much easier to determine the reason for the appeal and the appeal strategy with line item reporting. If the payor requires the code submitted as units on one line, the practice needs to be vigilant about watching to ensure the payor reimbursed on all three procedures
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| One, Two or Three Compartments in the Shoulder for Coding Purposes? |
August 7, 2009
Question:
We were once told that for the purposes of coding, that we could report an intra-articular debridement, subacromial decompression and debridement in the AC joint all together because the AC joint was a separate compartment in the shoulder?
Answer:
While the AC joint is a separate anatomic location and it is appropriate to report a distal clavicle resection with the above combinations, the debridement in the AC joint would not be reported separately as the AC joint is not a recognized as a separate compartment when reporting procedures such as a synovectomy or debridement.
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| Use of Operating Microscope and Lumbar Laminectomy/Lumbar Laminotomy Procedures |
July 23, 2009
Question:
I have a question about billing the 63030 (laminotomy) and 63047 (laminectomy) CPT codes with CPT code 69990 (microsurgical technique). Per the CCI edits the 69990 is not billable or payable is there something else out there that will override this?
Answer:
You are correct in that the CCI edits list 69990 as inclusive to CPT code 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar (including open or endoscopically-assisted approach) and CPT code 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis), single vertebral segment; lumbar) and will not allow a modifier to override the edit. Medicare has identified few surgical CPT codes where they will reimburse separate for the use of the operating microscope in addition to the surgical procedure. Medicare will not reimburse under any circumstances for the use of the operating microscope in addition to the laminotomy CPT code 63030 and the laminectomy procedure CPT code 63047.
However, it is not incorrect coding if the documentation supports that the operating microscope was brought into the surgical field to perform microdissection for microsurgery for the laminotomy/microdiscectomy. The use of the operating microscope is typically not medically necessary for the laminectomy with decompression defined by CPT code 63047.
Per the AMA CPT Manual, the instructional guideline identifies which procedures include the use of the operating microscope, thus CPT code 69990 would not reported in addition to any of the procedures listed. You will note that CPT code 63030 or 63047 are not identified in the list of procedures that include the operating microscope.
Operating Microscope (69990)
The surgical microscope is employed when the surgical services are performed using the techniques of microsurgery. Code 69990 should be reported (without modifier 51 appended) in addition to the code for the primary procedure performed. Do not use 69990 for visualization with magnifying loupes or corrected vision. Do not report code 69990 in addition to procedures where use of the operating microscope is an inclusive component (15756-15758, 15842, 19364, 19368, 20955-20962, 20969-20973, 26551-26554, 26556, 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571, 43116, 43496, 49906, 61548, 63075-63078, 64727, 64820-64823, 65091-68850).
Source: 2008 AMA CPT Manual. American Medical Association. 2007. Page 298. |
| How to Code for Anterior Approach to Spine |
July 8, 2009
Question:
Our spine surgeon recently performed an anterior spinal fusion (CPT code 22558) with the general surgeon. He and the general surgeon are looking for an anterior retroperitioneal approach code to report with the fusion. What CPT code does the general surgeon report?
Answer:
The approach by the general surgeon is included in CPT code 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
Both the spine surgeon and the general surgeon report CPT code 22558-62 for the first interbody fusion. In the CPT Manual 2008, Professional Edition, page 91, the graphic associated with CPT code 22558 states, “Anterior Approach for Lumbar Fusion (Anterior Retroperitoneal Exposure). This sometimes creates confusion on how to report this service. This confusion is not uncommon, as the definition of CPT code 22558 is Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
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| Infected Joint after THR |
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April 16, 2009
Infected Joint after THR
Question: Our surgeon performed a right total hip arthroplasty on a patient one month ago. At this time the patient presents with a hip infection and was returned to the operating room where the physician performed an I&D of an infected joint and placed antibiotic “patties”. We are unsure how to report the work the surgeon documented. The surgeon did not remove the prosthesis.
Answer: If the surgeon’s documentation supports a hip arthrotomy with I&D, we recommend looking at CPT code 27030 Arthrotomy, hip, with drainage (e.g., infection) plus CPT code 11981 Insertion, non-biodegradable drug delivery implant for the cement “patties.”
Both procedures would be appended with a modifier 78 and CPT code 11981 would additionally have modifier 51 appended after the modifier 78. Thus, you would submit as follows:
27030-78
11981-78, 51
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Trans S1 AxiaLIF / XLIF
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March 20, 2009
Question: I have surgeon that is doing a Trans S1 AxiaLIF and a XLIF (different patients). The company rep told him that he should bill the 22558 for the arthrodesis. I just don't know if I agree with that considering that both of these procedures are done with the patient in the prone position. They argue that they are removing the disc anteriorly. Are others doing this and what are you using the 22558?
Answer: Good news! The Trans S1 AxiaLIF procedure received a new code in 2009 – 0195T.
0195T Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace.
+0196T each additional interspace (List separately in addition to
code for primary procedure)
The XLIF (extreme lateral interbody fusion) is best reported using 22558.
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| Casting Supplies: Part of the Global Package or Not? |
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March 1, 2009
Q: When a physician puts on a cast in the office, can we bill separately for the supplies or are the supplies part of the cast application code?
A: In the office setting where the physician incurs the expense of the casting supplies, the supplies are always separately billable, whether it is the first or subsequent casts. Medicare does not include the payment for the supplies in the cast application codes, and therefore instructs the physician to use the appropriate Q codes when reporting services to their beneficiaries.
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