This month’s coding column addresses commonly asked questions related to orthopaedic coding and reimbursement issues under the American Medical Association’s (AMA) Common Procedural Terminology (CPT) rules.
Q: Previously, we were instructed to report the work associated with the coflex® interlaminar technology as an unlisted code. We are having significant difficulties in getting paid and want to ensure we are billing the service correctly. Is the unlisted code still the correct CPT code to report when this technology is used?
A: The AAOS and the North American Spine Society continue to recommend using the unlisted code for this procedure because Food and Drug Administration (FDA) approval of coflex requires that it be performed with a traditional laminectomy for decompression. A laminectomy is not separately reportable with Category III code 0171T.
Modifier 51 or 59?
Q: CPT says to use modifier 59 for separate site procedures, which is confusing to us. Which modifier do we append when the surgeon administers an injection to a large joint, such as the shoulder (20610), and also injects an intermediate joint, such as the elbow (20605)?
A: The modifier 51, modifier 59 debate presents much confusion in orthopaedic coding. Modifier 51 (multiple procedures) is used when two stand-alone procedures are reported and, by definition of the services, are not related to each other. Modifier 51 does not require that any special rules, other than the documentation of the service and medical necessity, must be met.
Modifier 59 is reported when a code combination could be considered inclusive to each other or special rules have to be met to report the code combination.
In the situation cited, report 20610 and 20605-51. CPT instructs that modifier 59 should only be used if a more descriptive modifier is not appropriate. In this scenario, the code descriptions identify separate locations (intermediate and large joints) that are not considered inclusive to each other. CPT code 20610 is linked to a shoulder diagnosis, while CPT code 20605 is linked to an elbow diagnosis.
Surgery for FAI
Q: Our surgeon typically performs arthroscopic hip procedures for femoroacetabular impingement (FAI) syndrome. Recently, the surgeon performed the surgery as an open procedure. How should this procedure be reported?
A: FAI surgery is being performed more frequently as an open procedure. Report code 27299, unlisted hip procedure, because there are no specific CPT codes when this surgery is performed as an open procedure. When requesting preauthorization for the surgery, note that the procedure has an unlisted code and that the most similar codes are 29914, 29915, 29916, 27033, or any combination, as appropriate.
Remember, CPT codes 29915 and 29916 are inclusive to each other when performed arthroscopically and would be considered inclusive in determining the fee for the unlisted procedure. Do not report the arthroscopic codes when the FAI procedure is performed as an open procedure.
Diskectomy and stenosis procedures
Q: The surgeon performed a laminectomy, facetectomy, foraminotomy, and decompression at L4-5 for a diagnosis of spinal stenosis. A laminectomy with diskectomy and decompression was also documented at L5-S1 for a diagnosis of protruded lumbar disk. Should the second-level surgery (L5-S1) be reported with the add-on code 63048? Or should a second primary code (63030) be reported for the diskectomy at L5-S1?
A: These procedure codes are directly related to the diagnosis. CPT code 63047 is reported for the surgery at L4-5 linked to the stenosis diagnosis. CPT code 63047 is a unilateral/bilateral code and is reported one time per lumbar level.
The surgery at L5-S1 is reported as 63030-59 to indicate a distinct procedure was performed at a different level and is linked to a disk diagnosis. CPT code 63030 is considered a unilateral procedure and may be reported bilaterally when the surgeon performs a right and left diskectomy. Do not confuse the coding of these procedures; they are diagnosis-driven CPT codes.
Reporting ACL reconstructions
Q: I am new to orthopaedic coding and base my reporting of services on Medicare rules. Recently my manager questioned my coding of anterior cruciate ligament (ACL) reconstructions, which I reported with CPT codes 29888 and 20924. I have been reporting this code combination routinely because I could find no edits in Medicare’s Correct Coding Initiative (CCI). Is this correct?
A: No, this code combination in the pure sense of the procedure description is not separately reportable, with perhaps one exception. But before we discuss that possible exception, remember that all services should be reported according to the AMA CPT coding rules.
Medicare’s CCI edits are payment rules for Medicare Part B. Medicare assumes correct coding and does not include edits for every possible code combination. Instead, Medicare creates edits when there has been an abundance of incorrect code combinations or when the likelihood exists that code combinations will be reported together incorrectly because the distinct procedural service rules are not met.
The ACL reconstruction code is valued to include the harvest of the tendon graft, typically harvested via an open incision. CPT code 20924 is not separately reportable with CPT code 29988 except, perhaps, in very rare instances when medical necessity requires the harvest from the contralateral extremity. Because ACL reconstructions are not typically reported to Medicare Part B, Medicare would not identify incorrect coding patterns that necessitate the creation of an edit.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.