Significant changes to orthopaedic-related codes and guidelines
The orthopaedic-related Current Procedural Terminology (CPT) codes and guideline changes for 2011 are significant. Surgeons and coders should pay special attention to the new, revised, and deleted codes and introductory guideline changes, as well as the new “Coding Tips” throughout the 2011 CPT manual. This article reviews selected orthopaedic code changes for 2011.
E & M services
Evaluation and management (E & M) services are hot. Specific guideline updates have been added throughout the section, and a new code category is being introduced—Subsequent Observation Care codes (99224–99226). These codes should be used to report billable services provided when the patient is in an outpatient area designated as “observation.” The new category includes physician work encompassing the initiation of observation status, supervision of care, and interval visits while the patient remains under observation.
Orthopaedic surgeons can report these services if their care is related to a condition other than services included in the global surgical package. The documentation requirements mirror the Subsequent Hospital Care codes, under which only two of the three key components are met and the services are related to medically necessary interval reassessments.
A newly introduced coding concept related to the reporting of wound débridements is also significant. The code range 11040–11044 has been completely revised; the major changes are as follows:
- CPT codes 11040 and 11041 have been eliminated; they are replaced by CPT codes 97597 and 97598 as appropriate for débridement of dermal and epidermal skin layers. Check the manual for the new definitions.
- The reporting of wound débridement is now based on the depth of tissue débridement and the size of the wound in square centimeters.
- Surgeons must “sum” the surface areas of multiple wounds of the same depth; each wound should be reported separately if the tissue débridements are of different depths.
- New add-on codes (11045, 11046, and 11047 for each additional 20 sq cm, based on the depth of the débridement) were introduced.
As a result of these changes, CPT code 11042 now reads, “Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less.” The associated new add-on code 11045 should be reported for each additional 20 sq cm or part thereof.
Additionally, the surgeon’s documentation must include the size of the wound(s) (eg, 4 cm x 5cm) and the depth of tissue débridement for each individual wound for which the procedure is performed.
The guidelines for the repair (closure) codes were revised related to the definition of a complex repair, and the definition of débridement and services included have been added to the repair codes. Surgeons performing complex repairs are now allowed to report this work separately when done in conjunction with débridement codes, excision of benign or malignant lesion codes, excisional preparation of a wound bed codes, or débridement of an open fracture or open dislocation codes.
Changes to the skin substitutes guidelines reinforce the range of codes that are “skin substitutes” and include specific instructions for using these codes. As an example, skin substitute codes should not be reported when the products are used as mesh or for internal reconstructive work such as a rotator cuff repair. These codes should only be reported when the product is used as a skin substitute.
A Category III code (0232T), introduced in July 2010 for the administration of platelet-rich plasma (PRP), is listed as a new Category III code in 2011. To coincide with the introduction of the new code, CPT added related guideline instructions.
Two CPT codes (20551—Injection[s]; single tendon origin/insertion—and 20926—Tissue grafts, other [eg, paratenon, fat, dermis]) reference the PRP Category III code for the work associated with the injections. Because this is an all-inclusive code, PRP used as an adjunct to surgical procedures is not separately reportable. The patient’s insurance benefits should be verified so surgeons fully understand the payer’s policies related to this procedure.
The following three hip arthroscopy codes have been added in 2011:
- 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
These codes include synovectomy and labral débridement/chondroplasty when performed at the same session. CPT code 29916 (labral repair) should not be reported when the repair is performed secondary to an acetabuloplasty.
CPT code 20930 was revised to include placement of osteopromotive material as one of the types of material used in the procedure. It now reads “+20930—Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure).”
Additionally, CPT code 20931 was revised to reference its applicability in spine surgery only. It now reads “+20931—Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure).” Both 20930 and 20931 may be used in conjunction with codes 22319, 22532, 22533, 22548–22558, 22590–22612, 22630, 22800–22812, 0195T, and 0196T.
Refer to the CPT manual for guideline changes related to CPT codes 22851, 63075, and 63076, as well as a cross-reference following CPT code 22614. A key change to CPT code 22851 is the deletion of the reference to threaded bone dowels, which are now reported with CPT code 20931.
Two new codes—22551 and 22552—continue the trend of moving away from component coding in spine surgery to the use of a more comprehensive code. Based on the frequency of reporting of anterior cervical discectomy/decompression procedures with an anterior interbody fusion procedure, the following new code and an add-on code were introduced for the cervical spine when both procedures are performed at the same site, same setting:
- 22551—Arthrodesis, anterior interbody, including disk space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
- +22552— Arthrodesis, anterior interbody, including disk space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
The guideline instructions for CPT codes 63075 and 22554 instruct the surgeon to not report the two codes together when both procedures are performed at the same site and the same level during the same session.
New Category III codes and guideline changes have been added for spine injections. The specific guidelines sections include updates on paravertebral spinal nerves and branches, as well as new codes for neurostimulator placement.
Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices. This article has been reviewed for accuracy by the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail firstname.lastname@example.org