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Answers to your coding questions

By Mary LeGrand, RN, MA, CCS-P, CPC

Plus tips to help you get paid correctly

Because coding questions always cover a range of topics, this issue of AAOS Now focuses on answering several recent inquiries. We’ve also included some coding suggestions designed to help you get paid correctly the first time around. Remember, new common procedural terminology (CPT) codes require you to be aware and update your reporting.

Outdated code usage means denials
Q: I am a new manager of an orthopaedic practice. I’ve noticed that when we submit 76075 for a dual-energy x-ray absorptiometry (DXA), we are often denied. Why?

A. You may have more denials—76075 is a 2006 code that was changed in 2007 to 77080.

Tip: Do a thorough review of the code changes for 2008; they are extensive. Words, even nuanced ones, matter. Surgeons should have a summary sheet that they can refer to when dictating because new habits take time to develop.

In the business office, updating means reviewing all charge tickets, superbills, or “cheat sheets” used in your office. It also means cleaning up the master computer files. Using old codes and old verbiage will result in delays and denials.

For example, many office encounter or surgical charge entry forms may still include codes 99271 and 99272 for a second opinion or codes 99261-99263 for a follow-up inpatient consultation, even though those codes were deleted some time ago. Give your forms a face lift! Assign this responsibility to a specific individual and ensure that it is done.

22899: Unlisted spine procedure
Q: One spine surgeon in our group uses the term “dynamic stabilization” in his dictation, and another uses “percutaneous vertebroplasty.” Should both be coded and reported as 22899 (unlisted spine procedure)?

A. The two procedures are not the same. With regard to “dynamic stabilization,” some controversy exists among spine surgeons on whether to report the unlisted code or the instrumentation codes for dynamic stabilization procedures.

The official CPT definition for code 22840 is “Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation).”

The definition of code 22842 is “Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments.” If the work performed and documented does not support the instrumentation codes, report the unlisted code 22899.

Use these definitions as your guide. Any time an unlisted code is used, the surgeon should include a full description of the procedure. A strong prior approval process is also recommended.

The next part of the question deals with percutaneous vertebroplasty. Because CPT codes for percutaneous vertebroplasty procedures on the lumbar and thoracic spine exist, the use of an unlisted procedure code is not necessary.

For example, if the operative note dictated by the surgeon reads “percutaneous vertebroplasty at L3 and L4 using fluoroscopic guidance,” you would report using code 22521 for L3 and code 22522 for L4. If the surgeon documents the supervision and interpretation of the fluoroscopic guidance and dictates a separate radiological report, you would additionally include code 72291-26.

Using the unlisted spine procedure code (22899) would be inappropriate because it applies to additional lumbar or thoracic levels. You may want to include an explanation of why the unlisted code was used along with the operative note. Some surgeons have found success by also referencing a comparison code.

If the vertebroplasty is performed on the cervical spine, report the unlisted procedure code 22899 or an S code. S codes are temporary Healthcare Common Procedure Coding System (HCPCS) codes and are not recognized by Medicare.

Q. When can an S code be used for a percutaneous vertebroplasty?

A. First, understand that S codes are not accepted by all private payors. Some payors may instruct you to use the S code S2360 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical). But this doesn’t mean all payors will accept this code; they won’t.

In the absence of a Medical Policy indicating preference for an S code, use the unlisted procedure code (22899) for a vertebroplasty on the cervical spine for Medicare and all other payors.

Tip: Determine which, if any, Temporary National Codes are accepted by your five largest health plans.

Debate on 22851 or 20931 stirs office discussion
Q: When a spine surgeon performs a posterior lumbar interbody fusion (PLIF) procedure using a structural allograft as the interbody device, is the right code 22851 or 20931?

A: If the surgeon documents the placement of a structural allograft in a PLIF, the appropriate bone graft code is CPT code 20931. Remember, however, that you may report this procedure only one time, regardless of the number of allografts placed.

CPT code 22851 is defined as “application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace.” This code can only be used with the placement of a cage, threaded bone dowel, or methylmethacrylate. Cages may be reported one time per interspace. If any other type of structural allograft is placed, CPT code 20931 must be used.

If a surgeon performed and documented the placement of cages bilaterally at L3-4 and L4-5, the surgeon would report code 22851 once for the two cages at L3-4, and code 22851-59 for the two cages at L4-5. The modifier 59 may not be necessary because the 2008 CPT Instrumentation Code Changes changed the code status from exempt to add-on. But because you are reporting the same CPT code twice, you may want to use the 59 modifier to indicate that the second code is not a duplicate, but additional bilateral cages at a second interspace.

Tip: Monitor Explanation of Benefits forms from all payors carefully.

59 modifier changed in 2008
CPT instructions, as well as the Correct Coding Initiative (CCI), say to append modifier 59 when the physician performs one of the following activities:

  • treats the same patient during a different session
  • treats a different site or organ system (In the example above, the second cage meets this definition. Because the same CPT code is reported twice, it would require differentiation from the first code.)
  • makes a separate incision or excision
  • treats a different lesion
  • treats a separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual

Tip: The easiest way to determine if the procedure is “separate” according to the CCI is to use the AAOS CodeX tool.

Lumbar artificial disk replacement
Q: Is the lumbar artificial disk replacement (LADR) procedure Medicare-approved? Sometimes they pay us, sometimes they don’t, and the same is true with other carriers.

A: Yes, Medicare covers the LADR procedure (CPT code 22857), under certain specific circumstances. The reason you have been paid sometimes and not others may be due to Medicare’s age ruling.

This past fall, Medicare said that LADR “is not reasonable and necessary for the Medicare population over 60 years of age.” Given that most individuals do not qualify for Medicare until they are 65, that eliminates just about all Medicare beneficiaries.

If a patient has commercial coverage for this procedure, and the surgeon performs LADR at two interspaces, you would report code 22857 for the first interspace, and code 0163T for the second interspace. The T codes were instituted in 2002 to allow data collection for emerging technologies, services, and procedures. Reporting these procedures is important for the following two reasons:

  • They are the correct codes and should be used instead of an unlisted procedure code.
  • The American Medical Association and the AAOS are tracking usage to determine the necessity of creating new CPT codes to meet the needs of orthopaedic surgeons nationwide.

You can find a list of orthopaedic-related T codes in CodeX or check the tab labeled “C III” in the professional edition of CPT 2008. A new T code in 2008 is 0183T—Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day.

Diagnosis coding for postoperative visits
Q: For postoperative visits, we use code 99024, which we track in our computer system. What ICD-9 code should we use?

A: Tracking postoperative visits is important because some concern exists in Washington, D.C., that surgeons whose global fee includes postoperative visits aren’t seeing patients as many times after surgery as expected. If true, a reduction in the global fee would be justified. Postoperative visit tracking during the global period is also important for practices as an aid for determining resource usage and for quantifying the costs of specific services.

Use the following diagnosis codes with code 99024 to track the reasons for postoperative visits:

  • V58.30—encounter for change or removal of nonsurgical wound dressing
  • V58.31—encounter for change or removal of surgical wound dressing
  • V58.32—encounter for removal of sutures

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org

AAOS Now
February 2008 Issue
http://www.aaos.org/news/aaosnow/feb08/managing1.asp