Mary LeGrand, RN, MA, CCS-P, CPC
This column addresses recently asked questions on coding orthopaedic procedures. Remember, you can direct specific coding questions to the AAOS for review by the Coding, Coverage, and Reimbursement Committee and AAOS staff. Visit www.aaos.org/coding for more coding information.
Injections with ultrasound guidance
Q: Can the ultrasound guidance CPT code—76942—be reported when the physician performs a major joint injection (CPT code 20610) using ultrasound guidance?
A: There is no AMA CPT coding restriction to reporting CPT code 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when ultrasound guidance is medically necessary to accurately place the needle for the injection. However, in most cases, imaging guidance to penetrate an easily palpable joint seems neither reasonable nor necessary.
CPT code 76942 has both professional and technical components, meaning that a separate radiology report (not part of the procedure note) is required to meet the code’s radiology requirements. The specific documentation requirements for ultrasound guidance include the following:
- A final, written report should be issued for inclusion in the patient’s medical record.
- Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.
- Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.
Although reporting code 76942 with the joint injection code 20610 is permissible, many payers are denying this service as not medically necessary. For example, under the Florida First Coast Medicare local coverage determination (LCD) 29307, “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”
Other Medicare carriers, such as National Government Services, have initiated payment recoupments for CPT code 76942 on the basis of lack of medical necessity.
Postoperative wound infection
Q: A postoperative wound infection developed 2 weeks after a thoracolumbar spinal procedure. The surgeon documented a surgical subfascial irrigation and débridement at T10 through L5. The CPT book includes codes for the procedure in both the cervical/thoracic and the lumbar/sacral regions. Should both codes 22010 and 22015 be reported for this return to the operating room during the global period?
A: This question was specifically addressed when the two codes were introduced in 2006. According to CPT, “Incision and drainage at the thoracolumbar junction would be reported with the code describing the region where the majority of the work is performed.”
In this scenario, the majority of the procedure was performed in the lumbar spine. Thus, CPT code 22015 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; lumbar, sacral, or lumbosacral) should be reported. Modifier 78, indicating a return to the operating room for a related procedure, should be appended to indicate this was an unplanned return during the global period of the original procedure.
Epidural fat graft
Q: The spine surgeon performed a lumbar laminectomy, decompression, and diskectomy at L4-L5. He documented the placement of an epidural fat graft at the end of the procedure. Is this service included in the more extensive surgery or can he report a graft code in addition to the other surgical procedures?
A: The epidural fat graft is not separately reportable and is considered inclusive to the more extensive procedure.
Q: The surgeon documented the following on a shoulder procedure: intra-articular débridement of the anterior and superior labrum, intra-articular débridement of the supraspinatus, and an arthroscopic bursectomy. I coded this as an extensive débridement, 29823, and the surgeon is suggesting I consider coding 29823 for the intra-articular débridement and 29826 for the arthroscopic bursectomy. No surgical procedure was performed on the acromion.
A: It’s great news when coders and surgeons discuss the coding to ensure accurate reporting. In this case, you are correct in that the bursectomy becomes part of a débridement service. The definition of CPT code 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [ie, arch] release, when performed [list separately in addition to code for primary procedure]) indicates that a partial acromioplasty must be performed. Therefore, CPT code 29826 cannot be reported if no acromioplasty is performed.
Reporting vein conduit
Q: The surgeon performed two nerve repairs. Due to a gap between the nerve ends, he decided to place two allograft vein conduits to allow the nerve ends to regenerate and heal. The neurorrhaphy procedures are inclusive to the vein conduit, but we wonder if he can report CPT code 64910 (nerve repair; with synthetic conduit or vein allograft [eg, nerve tube], each nerve) twice.
A: Yes, you can. The definition of CPT code 64910 says “each nerve.” Thus, the code may be reported for each nerve where the procedure is performed. Report 64910 and 64910-59, appending modifier 59 to the second code to indicate that the distinct procedural service rules were met (separate procedure, separate site).
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.
If you have questions about coding or want to suggest a topic for a future coding article, email email@example.com
Do You Have a Coding Question?
The AAOS is your source for coding and reimbursement information. You can direct specific CPT and/or ICD-9 coding questions to AAOS staff in the following ways:
- Send your question via email to firstname.lastname@example.org
- Visit www.aaos.org/coding and click on “Submit a Coding Question” (member log in required).
- In addition, you can view the most frequently asked questions, organized by anatomical site. You’ll also find links to ICD-10 resources so you can prepare yourself and your coding staff for the transition. (See “Don’t Be Late for a Very Important Date.”)
- AAOS staff work directly with the Academy’s Coding Coverage and Reimbursement Committee, who review members’ requests for coding guidance.
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