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Coding arthroscopic knee procedures

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

Although coding arthroscopic knee procedures should be pretty straightforward, confusion persists around coding and reimbursement for chondroplasty and removal of loose or foreign bodies. This tends to result from a lack of understanding of the Current Procedural Terminology (CPT) coding rules and payor reimbursement rules.

Chondroplasty, loose/foreign body coding basics
According to CPT, code 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chondroplasty]) should be reported to indicate the performance of an arthroscopic chondroplasty in the medial, lateral, and/or patellofemoral compartment(s). This code may only be reported one time per surgical session and may only be reported if the chondroplasty is performed in a separate compartment from the primary surgical procedure.

Modifier 59, the distinct procedural service modifier, should be appended to indicate to the payor that the chondroplasty was performed in a separate compartment. CPT code 29877 should be used with all private payors, unless the payor has issued written instructions related to the reporting of this code.

As shown in Code X (Fig.1), code 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body [eg, osteochondritis dissecans fragmentation, chondral fragmentation]) may be reported in addition to other arthroscopic knee procedures, including arthroscopic chondroplasty and arthroscopic microfracture, if either of the following requirements are met:

  • The arthroscopic loose/foreign body was greater than 5 mm or
  • The loose/foreign body was removed through a separate incision or portal (not through the inflow or outflow portal)

If arthroscopic removal of loose/foreign bodies was the only procedure performed, the size or separate incision guidelines do not apply.

Medicare coding
There is no issue with reporting CPT code 29877 to Medicare if the only procedure performed is a chondroplasty, regardless of the number of involved compartments (ie, CPT rules apply). Likewise, reporting CPT code 29874 to Medicare if the only procedure is the arthroscopic removal of loose/foreign body is also not problematic. However, when either code 29877 or 29874 is reported in addition to another arthroscopic knee procedure, Medicare payment rules are different from CPT rules and can be confusing.

Medicare has created a separate HCPCS “G” code, G0289 (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage [chondroplasty] at the time of other surgical knee arthroscopy in a different compartment of the same knee). When billing Medicare, a physician has to use HCPCS code G0289 to report arthroscopic removal of loose or foreign bodies and/or arthroscopic chondroplasty in a separate compartment of the knee.

Figure 2 shows the Medicare Correct Coding Initiative (CCI) edits for certain CPT codes under CPT code 29881 (Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]). Both code 29877 and 29874 have a “0” modifier, indicating these procedures are inclusive to CPT code 29881 and may not be overridden with a modifier. Although Medicare shows the “0” modifier, it also provides written instructions in the General Policy Section of the Musculoskeletal Section of the CCI edits. Because Medicare does not include HCPCS code G0289 in the list of codes that may be reported in addition to CPT code 29881, some confusion may result.

The CPT Assistant (April 2003) gave the following instructions regarding HCPCS code G0289:

“This add-on code should be reported in addition to the knee arthroscopy code for the major procedure being performed. Code G0289 is only reported once per extra compartment, even if chondroplasty, loose body removal, and foreign body removal are all performed. The code may be reported twice (or with a unit of two) if the physician performs these procedures in two compartments, in addition to the compartment where the main procedure was performed.”

This means that CPT code 29877 should be reported to private payors when other arthroscopic knee procedures are performed and HCPCS code G0289 should be reported to Medicare when other arthroscopic procedures are performed. If the private payor denies CPT code 29877 and refers you to the CCI edits, you should appeal, using supportive documentation from CPT and the AAOS. If the private payor continues to deny the service, appeal using the Medicare information showing the bundled edits and the instructional paragraph that indicates both are separately reportable.

Example
The following example shows the coding application according to CPT rules for private payors and Medicare Part B.

Right medial meniscectomy and tricompartmental chondroplasty: Under CPT rules, you would report code 29881 (Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]) and code 29877-59 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chondroplasty]).

Under Medicare rules, however, you would report CPT code 29881 once and HCPCS code G0289 twice (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage [chrondroplasty] at the time of other surgical knee arthroscopy in a different compartment of the same knee). You may want to check with your local Medicare carrier to see if the G code requires a modifier 59. As an ‘add-on’ code, it should not require the modifier 59 in this scenario.

Tips to remember

  • Ensure that the operative note details support all procedures stated as performed in the procedure title.
  • Code all services according to the CPT coding rules and use the AAOS Complete Global Service Data for Orthopaedic Surgery as an adjunct to the CPT rules.
  • Report all services to private payors using CPT rules—except in scenarios where the payor has provided specific written instructions on reporting payor-specific exceptions.
  • Report HCPCS code G0289 to Medicare only (unless a private payor has provided specific written instructions related to this code).
  • Do not report HCPCS code G0289 to Medicare if the only procedure performed and documented is a chondroplasty. Instead, report CPT code 29877.
  • Report CPT code 29877 one time per operative session, regardless of the number of compartments and only if no surgery was performed in one compartment. Report HCPCS code G0289 per compartment if no surgery was performed in that compartment (eg, medial or lateral meniscal surgery).
  • Append modifier 59 when appropriate to let the payor know that the subsequent procedure is a distinct and separate procedure.
  • Watch reimbursements closely to ensure payors reimburse correctly on all code combinations.
  • Appeal inappropriate denials!

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices. The information in 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 aaoscomm@aaos.org

AAOS Now
May 2010 Issue
http://www.aaos.org/news/aaosnow/may10/managing2.asp