Commonly Miscoded Orthopedic Procedures: Thoughts From Coding Compliance Management's Cristina BentinWritten by Rachel Fields | December 15, 2011
Cristina Bentin, CCS-P, CPC-H, CMA, president of Coding Compliance Management, discusses several commonly miscoded orthopedic procedures.
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1. Minimally invasive lumber spinal decompression procedures. Many facilities continue to incorrectly code minimally invasive lumbar spinal decompression procedures with CPT code 63030 or CPT code 63047 to their commercial payors. In Nov. 2010, the AMA expressed disapproval for reporting either code since the MILD procedure is performed via indirect visualization — meaning the surgeon cannot directly see the surgical location (neural structures) with his own eyes. CPT codes 63030 and 63047 utilize direct visualization of neural structures. At that time, the AMA recommended reporting the unlisted code.
With the implementation of Category III code 0274T-0275T in July 2011, representatives from the North American Spine Society say the most appropriate reporting of the MILD procedure is reflected with Category III codes 0274T-0275T. Category III code 0274T applies to the cervical or thoracic region, whereas Category III code 0275T applies to the lumbar region.
Ms. Bentin says facilities should keep Category III codes — as well as S codes, unlisted codes and implant reporting issues — in mind when they negotiate new payor contracts. "When facilities negotiate contracts, they often don't involve coders in the process or specifically ask the payors about their reimbursement policies regarding Category III codes," she says. "The payor is not necessarily going to volunteer its reimbursement information if you don't ask." Keep in mind that Medicare does not currently recognize or reimburse an ASC for any of the above mentioned CPT or Category III codes.
2. Arthroscopic chondroplasty. Ms. Bentin says 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) — versus CPT 29879 — arthroscopy knee, surgical; abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling or microfracture. The latter code should be used when the physician performs an abrasion arthroplasty which requires a detailed description of debriding/microfracturing to bleeding bone.
In 2012, the choice between the two codes becomes even more complicated. Starting in 2012, chondroplasty procedures are inclusive of other commonly-performed arthroscopic meniscectomy procedures, meaning CPT 29877 bundles into CPT codes 29880 and 29881 for surgical arthroscopy of the knee with meniscectomy. Ms. Bentin says it is absolutely crucial that coders query physicians if they don't provide enough documentation to determine whether a chondroplasty or an abrasion arthroplasty was performed. "If the coders are lax in asking the doctor for more information, and he's lax in providing the documentation, they're absolutely going to lose reimbursement," she says. "If he performed the procedure described by CPT 29879, the coder could have reported that code in addition to any procedures performed."
Ms. Bentin adds that if the physician documentation describes the abrasion arthroplasty procedure in detail, the coder may report CPT 29879 once per compartment of the knee rather than just once per knee — if a true abrasion arthroplasty was performed in more than one compartment.
3. Claviculectomy. From an audit perspective, Ms. Bentin has seen facilities fail to report the arthroscopic claviculectomy (29824) because the physician documentation does not include the amount/size of the clavicle excised. She says some commercial carriers allow separate reporting of an open/arthroscopic claviculectomy regardless of whether the size of the excised clavicle is documented, whereas others have documentation and reporting requirements that include a minimal clavicle excision size before they will reimburse for the procedure. The AAOS and the AMA have indicated approximately 1 cm (8-10 millimeters) for the arthroscopic claviculectomy to be separately reported.
"Physician documentation should provide detail regarding all procedures performed to include the amount of the distal clavicle excised," Ms. Bentin says. "When not provided — if the carrier requires a minimal amount excised — the coder should query [the physician] rather than omitting the procedure altogether." Physicians should be encouraged to describe the entire procedure and to include details regarding the amount of the distal clavicle excised, and the coder should understand each carrier's requirements to ensure the procedure is accurately reported.
She says this particularly applies in 2012, when CPT 29826 — for an arthroscopic shoulder subacromial decompression — becomes an add-on code (+29826). If the coder omits reporting the arthroscopic claviculectomy (due to either documentation deficiency or failure to meet carrier's reporting policy), the facility will receive little to no reimbursement because the subacromial decompression add-on code cannot stand alone. "Reimbursement would then be based on the carrier reimbursement policies for reporting an unlisted procedure code," she says.
Learn more about Coding Compliance Management.
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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