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Here are eight coding tips for orthopedic procedures.
1. Arthroscopic shoulder debridement. Jessica Edmiston, BS, CPC, CASCC, vice president of coding for National Medical Billing Services, writes the following:
"Arthroscopic shoulder debridement (29822) is often bundled incorrectly. There are times when it is appropriate to unbundle 29822 with other shoulder procedures. For example, an arthroscopic rotator cuff repair is performed in addition to a subacromial decompression and the debridement of a labral tear. The labral tear is unrelated to the rotator cuff and the subacromial decompression and therefore should be reported with modifier -59."
2. Abrasion arthroplasty or microfracture of the knee. Ms. Edmiston continues:
Abrasion arthroplasty or microfracture of the knee (29879) is reported per compartment of the knee. For example, if the procedure is being done is both the medial and lateral compartments you would report 29879 twice and append modifier -59 to the second one. Also, it is important that the documentation supports debridement down to bleeding bone or drilling of holes.
3. Knee arthroscopy. Cristina Bentin, principal of Coding Compliance Management, writes the following:
One of the biggest challenges in coding knees occurs with the determination of reporting CPT 29877, arthroscopy knee, surgical; debridement/shaving of articular cartilage (chondroplasty) vs. CPT 29879, arthroscopy knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture. With detailed operative documentation, code selection isn't a challenge. However, documentation deficiencies will result in incorrect code selection and in some cases a loss in reimbursement. Consider the following excerpts from actual clinical documentation:
An example of poor documentation (original excerpt): "Next, I performed an abrasion chondroplasty in the lateral compartment. Attention was then turned to the medial compartment, where again, another abrasion arthroplasty was performed."
This documentation does not detail or describe the procedure and the verbiage is not consistent. The lack of clarity may lead some coders to code CPT 29877 once for the entire case. And why not? It gets the account coded and billed timely, correct? Absolutely not. Coding is based on detailed information that is very specific. When documentation leaves more questions than answers, the resolution would be to query the physician to verify the procedure performed and to receive more written clarification in the form of an addendum.
Let's look at the same excerpt after a query is made and an addendum is inserted into the operative report:
Better documentation (addendum to original excerpt): "In the lateral compartment, an abrasion arthroplasty was performed with debriding down to bleeding bone. Attention was then turned to the medial compartment, where again, an abrasion arthroplasty was performed with debridement down to bleeding bone."
Code selection for the description above would be CPT 29879 x 2 rather than CPT 29877 x 1.
4. Open rotator cuff repairs of the shoulder. Ms. Bentin continues:
Review CPT codes 23410-23412 to report open rotator cuff tear repairs (to include mini open rotator cuff tear repairs) with code selection determined by acute versus chronic conditions. Mini open rotator cuff tear repairs typically don't involve entry into the shoulder joint while the tear can still be visualized and repaired.
While CPT provides a parenthetical statement under CPT 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair), when directing the CPT user to report 23412 for mini open rotator cuff repair we still need to determine the final code selection based on the procedural description and whether the condition is acute versus chronic.
Coding tip: CPT code verbiage in 23410-23420 is specific for an acute versus chronic condition within its verbiage.
Documentation tip: The operative documentation should provide whether the patient has an acute versus chronic condition. If no indication is provided within the clinical documentation, CPT code determination cannot be made without physician query. To assume acute versus chronic will impact your facility's bottom line by roughly $150 for applicable Medicare accounts.
5. Platelet-rich plasma injections: Caryl A. Serbin, RN, BSN, LHRM, president and founder, and Robin A. Weakland, CPC, coding manager, of Serbin Surgery Center Billing, writes the following:
New code CPT 0232T (injection(s) platelet-rich plasma, any tissue, including image guidance, harvesting and preparation) went into effect July 1. This code is billable if it is the only procedure being performed or it is performed at different site than the surgical site. Instillation of the platelets by the surgeon into the surgical site is considered part of the total procedure and therefore this code is not applicable.
However, if a PRP injection is being done at the same surgical area, CPT 86999 (unlisted transfusion medicine procedure) can be billed when the blood draw and centrifuge is done by center staff and not an outside company or representative.
6. Meniscal transplantation. Paul Cadorette, CPC, CPC-H, CPC-P, CEDC, COSC, CASCC, director of education for mdStrategies, writes the following:
When a patient has arthritis that has destroyed the articular surface of the knee joint, it may be necessary to perform a total knee arthroplasty with a joint prosthesis. However, there are times when someone can have a severe meniscal injury, where a majority of the meniscus needs to be removed but the overall integrity of the cartilage on the joint surface is maintained. If the patient goes on to have continued pain, a meniscal allograft transplantation can be performed.
The procedure starts by arthroscopically removing any remaining portions of the meniscus. Holes may be drilled into the tibia to use as anchoring points or portions of the articular surface can be taken down for passage of the donor meniscus. The cartilage can also be roughened up to create a bleeding surface to aide in the healing process. Each physician will have their own preference when it comes to preparation of the joint space and fixation techniques. Once joint preparation has been completed, an incision is made, dissection is taken down to the joint with an arthrotomy on either the medial or lateral side of the knee depending on which meniscus is being replaced.
When an arthroscopy is initiated and followed by an open procedure, we are accustomed to only reporting the open procedure, but when you look at the CPT code description for this "arthroscopic" procedure, it includes an arthrotomy for insertion of a donor meniscus, so for the purposes of coding this remains an arthroscopic procedure. (Note: There isn't a CPT code for an open meniscal transplantation procedure.) Once the meniscus has been inserted and positioned within the joint space, it is sutured into place using arthroscopic visualization with the anterior and posterior horns attached to the tibia usually through the arthrotomy. The scope is then removed and the incisions are closed.
This service is reported as 29868 – Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
You would not report 29874, 29877, 29881 or 29882 if these procedures are performed in the same compartment as the meniscal transplantation.
7. Arthroscopic shoulder surgery. According to Lolita M. Jones, RHIA, CCS, a consultant specializing in ASC and hospital outpatient coding, billing, reimbursement and operations, when patients come in for arthroscopic shoulder surgery, coders will often assign a code for arthroscopic distal claviculectomy when, in fact, the physician may have simply removed osteophytes or spurs from the clavicle. "The removal of spurs from the clavicle should be coded as acromioplasty, and that's another area where the payor wouldn't know what's wrong and the ASC would walk away with too much money," she says.
She says even experienced coders may be tripped up by mistakes like this, simply because cases are shifting from the hospital setting to the ASC setting. "Years ago, you would only see these procedures in a hospital inpatient unit," she says. "Coders really need to bone up on anatomy and physiology and, [if they can], the ASC should invest in anatomy and physiology software."
8. Hammertoe repairs. Another common problem with orthopedic coding occurs with hammertoe repairs, Ms. Jones says. She says hammertoe repair CPT codes can be used for any technique used to repair a hammertoe, whether the procedure is done using a fusion technique or a hemiphalangectomy. "Some coders get hung up on technique and literally go and assign a code for fusion or for hemiphalangectomy, when there's actually a code that exists for hammertoe repair," she says.
In either case — whether the coder is mistakenly coding for fusion or hemiphalangectomy instead of hammertoe repair — Ms. Jones says this error will lose the ASC money.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.