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Frequently asked coding questions

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

Report codes properly to ensure payment

Attendees at the AAOS coding workshops frequently have questions about various aspects of coding. This month’s column covers several questions that apply to many practices.

Conscious sedation
Q: Is conscious sedation reportable by the physician who administers this at the time of a closed reduction?

A: Yes. Conscious sedation, Common Procedure Terminology (CPT) codes 99143-99145, may be reported by the physician who administers the medication in the hospital setting. These codes are age- and time-relative. Conscious sedation requirements call for the presence of a trained observer to monitor the electrocardiograph (EKG), pulse oximeter, and vital signs during the procedure, which should be documented in the medical record.

Conscious sedation is not reported separately if an anesthesiologist is present. Medicare no longer considers conscious sedation as an anesthesia service; the October 2006 Correct Coding Initiative edits said that these services would be reimbursed when documented. Because these codes do not have assigned relative value units, however, the claim will likely be denied and require an appeal.

If an anesthesiologist is present, you cannot report conscious sedation separately.

Billing for in-house athletic trainer
Q: Our practice employs an athletic trainer to perform some physical therapy services. Are the services provided by the trainer billable to Medicare?

A: This may pose a risk to the practice because Medicare clearly states that physical therapy services may be reported only by a qualified physical therapist. The athletic trainer may not bill for these patient services, even under incident-to rules for a Medicare beneficiary—unless, of course, the trainer is also a licensed physical therapist.

PA assistant-at-surgery denials
Q: We are having increasing difficulty in getting reimbursed for assistant-at-surgery services for our physician assistants (PAs). Is there a resource that identifies when an assistant should be paid?

A: The core issue here is that Medicare and other payors have payment policies that delineate the procedures in which an assistant surgeon will be paid—whether the assistant surgeon is a medical doctor or a PA doesn’t matter.

To determine whether an assistant-at-surgery is eligible for payment, you can check CodeX. The details for each procedure include a box for assistant-at-surgery and a number (Fig. 1). In the case of arthroscopic shoulder surgery, the surgeon may still ask the PA to assist—despite the fact that no payment will be made—because of the time savings or the convenience factor. Surgeons should be aware of which procedures they commonly perform that do not pay for an assistant-at-surgery. They can then make a decision on whether or not to schedule a PA.

For example, a surgeon performing an arthroscopic shoulder capsulorrhaphy may need the PA’s skill set with the arthroscopy. The surgeon reports 29806 and the PA reports 29806-AS (assuming Medicare or the payor accepts the AS modifier). Medicare will not reimburse for the PA but a private payor might. Because modifiers 80, 81, and 82 are physician modifiers, they should not be used for a PA who assists at surgery without written instruction from the payor.

In an arthroscopic anterior cruciate ligament reconstruction, a surgeon may require the assistance of the PA with the procedure and the graft preparation (Fig. 2). The surgeon reports code 29888 and the PA reports code 29888-AS. Medicare and other payors will reimburse for the PA who assists with this procedure.

In all instances, make sure the surgeon documents the medical necessity of the assistant and the work performed.

CodeX makes it easy to check the payment status for assistant-at-surgery for Medicare patients. Check the Web sites of other payors to see if procedures where an assistant-at-surgery will be denied or paid are listed. If the information isn’t online, call the carrier. Informed surgeons can then decide whether to have an assistant or not.

Another source for information is the 2007 Physicians as Assistants at Surgery Study by the American College of Surgery, which can be found online at http://www.facs.org/ahp/index.html

Click on the link to the study, which can be downloaded. Use the search feature to see if an assistant is approved for the procedure. Commercial payors typically rely on both resources to set their policies.

Profiling E&M services
Q: Our physicians are asking about profiling evaluation and management (E&M) services. We know that payors in Pennsylvania are profiling and reporting outcomes. Where do we begin?

A: Profiling physicians’ E&M services is a critical component of internal compliance that can help you identify potential audit risks as well as potential areas of overcoding or undercoding based on state and national trends. Private payors typically do not share data, although Medicare does. Additionally, an E&M analyzer that compares you against other surgeons in your state is available through KarenZupko & Associates, Inc.

Which code to use?

Q: Which code should be used for a “wrist denervation procedure,” also known as a “posterior interosseous nerve neurectomy?”

A: Posterior interosseous neurectomy (PIN) is reported with CPT code 64772, “Transection or avulsion of other spinal nerve, extradural.”

Q: We just learned that we can report the application of a wound vacuum dressing. What codes do we use?

A: Negative-pressure wound therapy is reportable when the documentation supports the service. In 2007, the AAOS updated the Global Service Data for Orthopaedic Surgery book to classify this as an “excluded service” for all musculoskeletal and integumentary codes. The following verbiage is in the “Intraoperative services not included in the global surgical package” section of Global Service Data:“2. complicated wound closure (eg, application of wound vacuum device to open wound) or closure requiring local or distant flap coverage and/or skin graft, when appropriate (eg, 13160, 14000-14350, 15000-15400, 15570-15776)”

CPT codes 97605 (Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters) and 97606 (Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters) describe the services; it may be necessary to append modifier 59 to indicate a distinct procedure if other services are reported at the same session.

Q: In his operative note, the surgeon describes the medical necessity of using an allograft for open reduction and internal fixation (ORIF) of a tibial plateau fracture due to the nature of the fracture and the need to repair the bone void. How is the allograft reported?

A: You cannot report the allograft separately because all allografts, except those used in spine surgery, are included in the surgical package. Report the appropriate ORIF tibial plateau fracture code based on whether the fracture was unicondylar (code 27535) or bicondylar (code 27536).

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
March 2008 Issue
http://www.aaos.org/news/aaosnow/mar08/managing1.asp