AAOS Now

Published 12/1/2016
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Michael R. Marks, MD, MBA

7 Golden Rules for Reducing Hip Arthroscopy Denials

If a constant stream of denials for hip arthroscopy procedures frustrates you, know that you are not alone. These denials are a common source of angst for physicians. The good news is, if you know how to avoid common coding pitfalls, document correctly, and follow payer medical policies, most of these denials will disappear.

The key is having proper documentation, prior to submitting the claim.

Hip arthroscopy from a coding context
This minimally invasive hip surgery is still relatively new. Although the number of Current Procedural Terminology (CPT) codes is expanding, carrier policies have not quite caught up with the orthopaedic community's acceptance.

A major challenge to getting paid for these arthroscopy procedures is the amount of ancillary work that can be done around the hip. If you don't understand what's bundled in with the three major CPT codes, how to bill for an unlisted code, and which modifiers to use, it's almost guaranteed your claims are destined for denial.

This article focuses on the correct use of following codes and modifiers, which generate the most questions in the workshops sponsored by the AAOS and KarenZupko & Associates (KZA):

  • 29914—Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)
  • 29915—Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
  • 29916—Arthroscopy, hip, surgical; with labral repair
  • 29999—Unlisted procedure, arthroscopy

Included in codes 29914, 29915, and 29916 are procedures such as dèbridement and removal of loose bodies less than 5 mm in size. That means you cannot bill for these procedures in addition to these three codes. You also cannot use modifier 59 (distinct procedural service). More on that shortly.

Speaking of modifiers, let's clarify the correct usage of the two modifiers most commonly used with the hip arthroscopy codes.

Modifier 51 (multiple procedures) is used to indicate that more than one procedure was performed through the same incision. Special rules for multiple endoscopic procedures apply if those procedures are in the same family (eg, another endoscopy that has the same base procedure). If an endoscopic procedure is reported with only its base procedure, separate payment for the base procedure is not made. Payment for the base procedure is included with the other endoscopic procedures.

Modifier 59 (distinct procedural service) is used to identify procedures/services, other than evaluation and management (E/M) services, that are not normally reported together, but are appropriate under the circumstances.

Generally, the more appropriate modifier for hip arthroscopy claims is -51 rather than -59. This is because, in general, all of the work done about the hip is related rather than being distinct, separate procedures. Hip arthroscopy does not have "add-on" codes as are seen in spine surgery, where the relative value units (RVUs) are already modified for the additional procedure, and the modifier 51 is not needed.

The 7 Golden Rules
With this background and overview of the codes and modifiers, here are the 7 Golden Rules to follow if you want to reduce hip arthroscopy denials to a trickle. (Golden Rule No. 6 explains why some denials can be expected.)
1. Know thy hip arthroscopy medical policies.

As nefarious and opaque as insurance companies can be, they are clear on one thing—their medical policies. These documents describe the nitty-gritty details about how to code for, document, justify medical necessity, and submit the claim for a particular procedure.

Plans make their medical policies available on their websites. To save hours of browsing time, simply type the name of the payer, "hip arthroscopy," and "medical policy" into your search engine. Direct your office staff to obtain and organize the policies for common procedures and plans.

Because policies—especially those related to newer technologies—change over time, it is important for your office staff to stay on top of the changes and update your coding compliance program as necessary. 

2. Document medical necessity in the assessment, preoperative visit, and operative note.

Although each payer's rules may vary, all carriers will look for evidence of medical necessity in your notes for unlisted procedures and appeals of a denied claim. Take the time to provide the details of the patient's story. This should include the duration of the problem, the treatments attempted, the findings upon physical examination, and radiologic studies. Use the Academy's Orthopaedic Code-X product, or register for an upcoming AAOS coding and reimbursement workshop if you are uncertain about how to document these basics.

3. Be prepared for preauthorization.

Because hip arthroscopy surgery is still relatively new, most plans require preauthorization. Proactively supply staff with the right notes that satisfy medical necessity (see No. 2, above) and medical reasonableness. If your note or the radiology report documents arthritis or degeneration within the hip joint, you will not obtain preauthorization. Don't push staff to schedule the patient for surgery until authorization is approved. If you rush to the operating room, you risk performing the procedure for free, and your chance of retroactive authorization for the hip arthroscopy is slim.

4. Submit the codes in the correct order on the claim form. 

This is basic coding, yet it's often overlooked. List the codes in order of highest RVU first. When multiple procedures are performed, the carrier will generally pay 100 percent for the first procedure, reduce the second procedure by 50 percent, and reduce additional procedures by a certain percentage per its payment policy. To receive the maximum reimbursement, order the codes from highest to lowest RVU. For example, the RVU for 29916 is 29.19; for 29914, it's 28.66. So, 29916 should always precede 29914 on the claim form. 

5. Don't use vague diagnosis codes.

A recent audit found that all claims from one practice were submitted with a preoperative and postoperative diagnosis of unspecified "hip pain" (M25.55 or M25.559). This diagnosis may be too nonspecific—especially for use in an appeal. Instead, use M25.551 or M25.552 (specifying laterality of hip pain). If osteophytes are present, use M25.751 or M25.752 (osteophyte right and left hip respectively). If the medical record documents another condition without a more specific ICD-10 code, consider using M25.851 or M25.852 (other specified joint disorder, hip [right and left, respectively]).

6. Be proactive when using unlisted codes.

The use of unlisted/unspecified CPT codes is fraught with denials and payment challenges. Being proactive is the best way to limit lack of payment and frequent appeals.

Here's a common scenario: The practice bills 29914 (femoroplasty), 29916-51 (labral repair), and 29999-51 (gluteus medius repair). The physician receives payment for 29914 and 29916-51 but is denied payment for 29999-51.

The reason? When an unlisted code such as 29999 is used, the original submission will probably be denied, with a payer request to submit the operative note. Following Golden Rule No. 2 ensures that the operative report clearly states the indications for the procedure, the medical necessity of the procedure, and exactly what was done during surgery that corresponds to the codes submitted. If you have the proper documentation, you are more likely to get paid for 29999 when you submit the operative note. Proactively including the right details in the note before you submit the claim will expedite your office staff's appeal and payment. In this scenario, documentation should support that the need for repair of the gluteus medius was not as a result of the approach. Be aware that the need for repair may be considered inclusive of the main arthroscopy codes.

7. Generally speaking, don't use modifier 59 (distinct procedural service) for hip arthroplasty procedures.

Lots of misunderstanding surrounds modifier 59, which is intended for use when a procedure is distinct from other procedures in the same operative session. In all fairness, the Centers for Medicare & Medicaid Services has never issued detailed, specific guidance for its use, although it has promised to do so. (A future article will address these new codes after they are implemented.) Physicians frequently use modifier 59 to "ensure" payment. Unfortunately, that doesn't work. Please refer to "Modifier 59 Revisited" (AAOS Now, March 2015) for a thorough discussion.

Débridement is a good example of a procedure that is included in hip arthroscopy codes 29914, 29915, and 29916. If you are coding separately for the removal of a loose body, make sure to document the size of the loose body (it must be > 5 mm) to ensure receiving payment.

To learn more about these two modifiers, refer to "The Differences Between Modifiers 59 and 51" (AAOS Now, June 2013).

Make sure you know the rules, document correctly, and justify medical necessity and medical reasonableness so you don't cheat yourself out of appropriate hip arthroscopy reimbursement.

Michael R. Marks, MD, MBA, is an orthopaedic surgeon and consultant with KZA. The firm partners with AAOS to deliver annual regional coding workshops.

Additional Information:
Hip Arthroscopy Case Example
Answer: Hip Arthroscopy Case Example