What to do when an established code doesn’t exist
Long-established procedures such as total joint replacements have Current Procedural Terminology (CPT) codes that are also part of a payor’s standard physician fee schedule. A new procedure, or a new method of performing an older procedure with a new device, however, may have neither a CPT code nor a listing in a payor’s physician fee schedule.
So how are you, as the billing surgeon, to report the procedure? Coding and billing of new technologies and procedures are very difficult for many practitioners and, if not done properly, can lead to incorrect reimbursement and denials.
One option is for you and your staff to research coding advice—a time-consuming and often frustrating task. No single easy reference resource exists, and some resources provide conflicting advice.
A second option is to rely on coding advice from the manufacturer. Although easier and quicker than personal research, this option can also lead to incorrect coding and billing. The payor may deny the claim; even worse, if the payor is Medicare, it may audit the practice for fraudulent billing.
As the billing surgeon, you are ultimately responsible for the code that appears on the claim form; simply following the advice of a manufacturer or any other source does not indemnify you from risk.
What’s a surgeon to do?
When you code for a procedure or a technology that doesn’t have an established CPT category I or category III code, you need to double—or even triple—check that the advice you’ve received matches the coding and billing practices of other surgeons.
You can submit your question to the AAOS, to the American Medical Association (AMA), or to other professional medical societies for clarification. The AAOS and many other associations have staff members who are certified professional coders; likewise, the AAOS and other associations offer a free or fee-for-service “coding hotline.”
A specific recommendation from the AAOS or any other medical association, however, does not represent the association’s official position unless it is published in an article or posted on the organization’s Web site. An e-mail, fax, or letter responding to your question does not constitute an official statement or position.
For example, AAOS coding advice can be considered official when it is published in AAOS Now, in the Journal of the AAOS, within an AAOS position statement, or in any AAOS text, such as the AAOS Musculoskeletal Coding Guide.
Any opinion rendered by an individual—either verbal or written—should not be considered as an official position or document. This is true for coding advice from the AAOS coding hotline, or from AAOS staff in response to member calls and e-mails. Although both the coding hotline and AAOS staff maintain high standards of quality, their recommendations do not carry any legal weight. These responses, therefore, will not be sufficient evidence in a court of law if you base an appeal on them. They might, however, be sufficient to win an appeal from an insurance company, but the insurance company is not legally obligated to accept them as binding.
Relying on a manufacturer’s advice
When a manufacturer distributes a product, it will almost always provide information about how to code and bill for the product and the accompanying procedure. In most cases, the advice is correct; however, the AAOS is aware of multiple cases where the coding advice provided by a manufacturer was incorrect or misleading.
In some cases, manufacturers have stated in their marketing materials (printed or verbal) that the AAOS recommends a certain method of coding and billing, even when the AAOS has done no such thing, or has only given advice, not an official recommendation. If you read or hear this claim, you should always ask for verification that the AAOS recommendation has been published.
If the manufacturer cannot document the source of the recommendation in an official AAOS publication, you should assume that the AAOS does not have an official recommendation. You should also e-mail or call the AAOS immediately and report the misrepresentation. The AAOS takes very seriously any improper misuse of its name by nonaffiliated parties and will investigate the situation to decide what, if any, action is required.
The following tips will help you properly code new procedures and/or the use of new technology:
- Always check to see if a CPT code currently exists to describe the technology and procedure. If a code exists that exactly matches the description of the procedure, you must use this code. CPT codes may be either category I codes (established procedures) or category III codes (emerging technology or T-codes). Except for “unlisted” codes (such as 23929, unlisted procedure, shoulder), Category I codes will always have an assigned Medicare relative value unit (RVU). Category III codes do not have assigned RVUs and should be treated similarly to unlisted codes; estimate the time and work involved in the procedure and submit a claim, accompanied by a detailed operative note, for the work.
- If the procedure does not have an assigned CPT code, use the most appropriate unlisted code and provide a detailed operative note explaining the work involved in the procedure. A complete list of unlisted codes can be found in the Orthopaedic Code-X, the AMA CPT® Professional Edition, and other sources.
- Do not assume that the manufacturer’s coding advice is correct. It is always better to be safe and verify the manufacturer’s advice with a third party, such as an association like the AAOS or the AMA, or a coding consultant.
- Always include a detailed operative note. If you are performing a new procedure that doesn’t have an established CPT code, the more information you provide with your claim, the more likely you are to get that claim paid and avoid a denial or audit.
- If you have questions, ask your professional association(s). Even if they do not have an official position on the technology in question, professional associations are likely to offer you additional guidance and clarification. If they do have official documentation related to the technology or procedure in question, they will be happy to provide you with copies.
- Exercise caution and regularly check AAOS Now for articles on CPT codes. Every year, AAOS Now publishes an article listing new CPT codes for that year. Most new technologies will receive a category III or category I code within a few years of their introduction, so coding of new technology will eventually be easier.
Matthew Twetten is senior health policy analyst for AAOS and serves as staff liaison to the AAOS Coding, Coverage, and Reimbursement Committee. He can be reached at firstname.lastname@example.org