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15 CPT and Coding Issues for Orthopedics and Spine

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At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 16, Stephanie Ellis, RN, CPC, with Ellis Medical Consulting, discussed 15 current procedure terminology coding issues for orthopedic and spine ambulatory surgery center facilities. She discussed coding issues for 15 procedures, citing the American Medical Association's Current Procedural Terminology.

CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

1. Lipoma Removals. Ms. Ellis said there are no specific CPT procedure codes for lipoma excisions but that it is important to code these accurately using appropriate codes from within the 10000-section (11400-11446) if the lipoma is located just under the skin. She said to use the 20000-section if the lipoma is removed from deeper tissue and a layered closure is performed.

2. Joint Injections. Ms. Ellis said to use CPT code 20600 for an arthrocentesis, aspiration and/or injection in a small joint or bursa (i.e. fingers and toes); 20605 for an injection in an intermediate joint or bursa (wrist, elbow or ankle, temporomandibular, acromioclavicular or olecranon bursa); and 20610 for an injection in a major joint or bursa (shoulder, hip, knee joint or subacromial bursa). This code can also be used if an SI joint injection is done without imaging.

3. Joint Manipulations. CPT guidelines are that if a surgical arthroscopy is performed on the same joint when a joint manipulation and/or joint injection are performed in the same case, only the scope procedure is billable.

4. Subacromial Decompression Procedures. A subacromial decompression with partial acromioplasty repairs is CPT code 29826. Open procedures for an acromionectomy are coded 23130. A coracoacromial ligament release is coded 23415.

5. Injections for post-operative pain control. "This needs to be done by a physician other than the orthopedic surgeon," Ms. Ellis said. "It has to be documented and put that the diagnosis is for pain control."

She said this should not be billed to Medicare, and said to put a 59 modifier on it because it's unbundled from surgery. Injections for post-operative pain control cannot be part of the surgeon's operative report or part of the anesthesia record.

6. Meniscus procedures. If a meniscectomy procedure is performed in both the medial and lateral compartments arthroscopically, use CPT code 29880, Ms. Ellis said.

Meniscal repairs are billed with code 29882 for an arthroscopic repair in the medial or lateral compartment.  Arthroscopic meniscal repairs performed in both the medial and lateral compartments should be coded 29883.

Ms. Ellis also discussed a CPT guideline change that affects knee scope coding. The AMA revised the arthroscopic knee meniscectomy codes 29880 and 29881 to include a code 29877 debridement/chondroplasty procedure in the same or other compartments.  "What this means is that if a chondroplasty is performed on the same knee in the same case as a meniscectomy, even if it was the only procedure performed in a knee compartment, it cannot be separately billed with codes 29877 or G0289," Ms. Ellis said.  

7. ACL repairs and reconstructions. Arthroscopic ACL repairs are coded 29888, Ms. Ellis said. She said to use code 27407 for an open ACL repair.

She also noted that the hamstring autografts harvested from the back of the same knee are not separately billable.  Bill purchased allografts with code L8699 or other appropriate implant code, Ms. Ellis said.

8. Epicondylectomy procedures. CPT code 24357 is for a percutaneous tenotomy of the proximal extensor carpi radialis brevis tendon at its insertion in the elbow. Code 24357 is for the open debridement of soft tissue or bone in the elbow. This code is used when the surgeon removes damaged soft tissue and, at times, bone. Code 24359 is similar, but should be used when a surgeon also repairs the affected tendon or does a tendon reattachment, Ms. Ellis said.

9. Epidural steroid injections. These are also known as translaminar injections. She said these should not be confused with transforaminal ESI procedures. CPT code 62310 is for a single ESI injection, whereas code 62311 is a lumbar or sacral ESI injection.

10. Tranforaminal epidural injections. When performed for dates of service beginning Jan. 1, 2011, the cervical/thoracic and lumbar sacral injection codes have been revised to now include the use of imaging — fluoroscopy or CT scan. Billing separately for these types of imaging is no longer allowed.

She noted that if a physician does an ESI (CPT code 62311) at level L5 and a transforaminal ESI (64483) at L4 or L5, the procedures are unbundled and not both billable. Only code 62311 would be billable in that case.  However, if the physician does an ESI (62311) at level L5 and a transforaminal ESI (64483) at area L3 or L4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the second code after the 62311 ESI code on the claim form.

11. Facet joint nerve injections. These injections are also referred to as select nerve root blocks and have a different code for each level billed. The last code allowable for each spinal area is for the third level, and it cannot be billed more than one time per day, which in CPT rules means that only a maximum of three levels are allowed to be billed. If the physician performs facet injections at a 4th level or beyond, there is no code for those levels and they are not billable, Ms. Ellis said.

12. Sacroiliac joint injections. These are the only procedures where the CPT codes the ASC facility uses and the physician's way of billing may differ. The codes are 27096 or G0260.

G0260 coding, used for injection procedure for sacroiliac joint, are to be billed by ASC facilities only, Ms. Ellis said.

The ASC should use the G0260 code to bill SI joint injections to Medicare, while physician claims are billed to Medicare with the 27096 code. The reason for the differing codes is that G0260 is on the Medicare ASC list of covered procedures, but 27096 is not.

13. Radiofrequency procedures. ASCs should use code 64633 for the destruction of paravertebral facet joint nerves by neurolytic agent with fluoroscopy, or CT image guidance for a cervical or thoracic single facet joint procedure for the first level performed. The add-on code for additional levels is 64634.

Code 64635 is for procedures on lumbar or sacral single facet joints for the first level. The add-on code for additional levels is 64646.

14. Discograms. Ms. Ellis said to append the modifier -59 to the second, third and fourth procedure codes, depending on your carrier requirements, to help avoid a payor denial.

15. Spinal fusion procedures. When anterior cervical fusions are performed, usually a discectomy is also performed. Ms. Ellis said for dates of service in 2010 and before, two codes — 63075 for the discectomy and 22554 for the fusion — were required.  Starting in 2011, CPT combined these two procedures into one new code.  Ms. Ellis said to use code 22551 for the first level of fusion and discectomy performed and to use add-on code 22552 for subsequent levels.  

Ms. Ellis said CPT codes 63075 and 22554 are still valid for use in cases where only those individual procedures are performed and they are not combined.

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