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Tips to Tackle Four Common Orthopedic Coding Challenges

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Thile the expanded list of Medicare-approved procedures may have resulted (or will result) in your ASC’s performing new procedures this year, this does not mean you can or should be any less careful with how you code your older procedures. In fact, you will want to work diligently to perfect your coding of existing procedures so you can have more time available to spend on the new cases your ASC performs. Thile the expanded list of Medicare-approved procedures may have resulted (or will result) in your ASC’s performing new procedures this year, this does not mean you can or should be any less careful with how you code your older procedures. In fact, you will want to work diligently to perfect your coding of existing procedures so you can have more time available to spend on the new cases your ASC performs.

Here are tips to help you with four common orthopedic procedures that are often coded incorrectly, according to Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting in Brentwood, Tenn.

Lipoma removals
Lipomas are benign fatty tumors found in the subcutaneous or deeper soft tissue areas. They can occur on the chest, back, flank, neck, shoulder, arm, hand, wrist, fingers, hip, pelvis, leg, ankle or foot. Lipomas can be of varying depth into the tissues, as superficial as the subcutaneous tissue or extending deep into the intramuscular tissues.

Considering all these factors, it is very important to code the removal of lipomas carefully and accurately, says Ms. Ellis. Use the appropriate code from the 10000 section (11400–11446) if the lipoma is located in the subcutaneous tissues. Use a code from the 20000 section of codes if it is removed from a deep intramuscular tissue area, she advises.

Fracture care
There is new language this year for many of the fracture codes. CPT revised the procedure’s descriptor to say it “includes internal fixation when performed,” and the codes now exclude external fixation, says Ms. Ellis.

“The previous language on many of the fracture codes was ‘with or without internal or external
fixation,’” she says.

When your physicians use external fixation, CPT says this can be coded and billed in addition to the fracture care procedure. However, since this change is in the CPT code wording, Medicare may not necessarily agree with the separate billing of external fixation from the fracture code.

“It would be wise to check the Correct Coding Initiative  unbundling material each time — to be sure the codes are not bundled — when billing for external fixation,” she advises.

Hardware removals
You should use code 20680 for deep pin removal procedures, which are commonly performed in an ASC. During this procedure, the physician makes an incision overlying the site of the implant. Deep dissection is carried down to visualize the implant, which is usually below the muscle level and within bone. The physician uses instruments to remove the implant from the bone. The incision is repaired in multiple layers using securing material such as sutures and staples.

Be careful to review the procedure codes first billed when the original device was placed, Ms. Ellis advises.

“If the removal of the device was included in the original procedure code, it cannot be billed separately by the physician,” she says. “However, the ASC can bill for it.”

There are several methods for how many 20680 implant removal codes to bill when multiple pieces of hardware are removed.

“The method we recommend is to bill based on the number of incisions made to remove the hardware rather than the number of pieces of hardware removed,” she says. 

For example, if four incisions are made to remove a plate and six screws on the right side of the body, Ms. Ellis recommends billing 20680 four times using the following codes and modifiers:

20680-RT
20680-59-RT
20680-59-RT
20680-59-RT

Tendon grafts with ACL repairs
CPT code 20924, which is used for a tendon graft, indicates the graft must be obtained “from a distance” (from the surgical site). Billing for this code with the 29888 ACL repair code should not be done when the tendon graft is (commonly) obtained from a separate incision on the same knee, which does not constitute enough distance to bill for it
separately, according to the CPT Assistant
publication, says Ms. Ellis. 

You should bill for 29888 with the 20924 code when the graft is obtained from the opposite knee or either ankle, she advises.

Contact Rob Kurtz at rob@beckersasc.com.

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