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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
Here's one of those instances where you have a CPT code definition and the coder has to interpret the exact meaning of how the code should be applied. When that happens you invariably end up with a number of different interpretations and without additional information from a reputable source such as CPT Assistant to confirm the proper coding methodology there will be a lack of consistency from coder to coder and probable denials because the facility and physician coding does not match.
Take the following scenario; a patient presents for open repair of a ruptured quadriceps tendon. Here are some of the different opinions as to how the procedure should be reported along with arguments for not reporting the procedure that way.
• Opinion: CPT code 27385 should be assigned because the tendon is part of the quadriceps muscle
• Argument: You should not use 27385 because the CPT code definition specifically states quadriceps "muscle" repair and the tendon is not the muscle
• Opinion: Report CPT code 27664 repair of extensor tendon in the leg because this best describes a tendon repair and not a muscle repair
• Argument: It would not be appropriate to use 27664 because this code is found under the heading of Leg (Tibia and Fibula) and Ankle Joint, and these codes are used for the lower leg, not the thigh or knee which is where the quadriceps muscle/tendon is located.
• Opinion: There isn't a CPT code that accurately describes the service performed so you should report code 27599 Unlisted procedure, femur or knee.
What's your opinion? I always like to provide documentation before I'm willing to commit or recommend one code over another, and for me, that comes in the form of a recent AHA CODING CLINIC FOR HCPCS which states, "Although the code descriptor refers to the muscle, the muscle connects into bone via a tendon — therefore code 27385 is the correct code assignment for this procedure."
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.
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