Follow CPT rules for proper payments
Recently, a coder for a sports medicine group submitted the following question regarding the administration of a joint injection for pain management at the end of the case:
“A joint injection (20610) is listed as a component code of a meniscectomy procedure (29881) but the Correct Coding Initiative (CCI) edits indicate that the edit may be overridden with the use of the 1 modifier when appropriate. I assume I would have to use a modifier 59 to report the post procedure pain injection to override the edit.
“However, when I look at the Bankart procedure code (29806), there is no CCI edit listing the injection code 20610 as a component code to the Bankart procedure. Does this mean I can report 20610 for the postprocedure pain injection and use a modifier 51 since there is no edit in place?”
This is a great question because this line of thinking will consistently lead to coding errors. Coding must follow the American Medical Association’s (AMA) Current Procedural Terminology (CPT) coding rules, and coders should read all of the Medicare CCI Manual.
The introductory section of the CCI Manual includes the following instructions for physicians:
“The edits and policies do not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.”
Medicare is clearly stating that correct coding is the obligation of the physician, based on CPT rules, making it critical that the coder follow the AMA CPT rules.
Additionally, the Medicare Carrier Manual includes the following instructions to carriers on providing coding advice:
“Providers are responsible for determining the correct diagnostic and procedural coding for the services they furnish to Medicare beneficiaries. Customer Service Representatives (CSRs) shall not make determinations about the proper use of codes for the provider. When providers inquire about interpretation of procedural and diagnostic coding they shall be referred to the entities that have responsibility for those coding sets. There are four places that CSRs shall refer callers with questions about coding.
1. Current Procedural Terminology (CPT-4) codes are proprietary to the American Medical Association (AMA). As such, CPT coding questions from providers (with exception noted in 4 below) shall be referred to the AMA. The AMA offers CPT Information Services (CPT-IS). This new, Internet-based service is a benefit to AMA members and is available as a subscription fee-based service for nonmembers and nonphysicians. The AMA also offers CPT Assistant. Information about these resources is found at http://www.ama-assn.org/
2. ICD-9-CM related questions are handled by the American Hospital Association’s Coding Clinic. Details about this resource are available at http://www.ahacentraloffice.org/
3. Level II Healthcare Common Procedure Coding System (HCPCS) codes related to Durable Medical Equipment or prosthetics, orthotics, and supplies are answered by the Pricing, Data Analysis and Coding (PDAC) Contractor. Information about the PDAC and the services it provides can be found at https://www.dmepdac.com/
4. The American Hospital Association’s Coding Clinic for HCPCS responds to questions related to CPT-4 codes for hospital providers and Level II HCPCS codes, specifically A-codes for ambulance service and radiopharmaceuticals, C-codes, G-codes, J-codes, and Q-codes (except Q0136 through Q0181), for hospitals, physicians, and other health professionals who bill Medicare. Details about this resource are available at http://www.ahacentraloffice.org/. Additional information can be found about these resources at: http://www.cms.hhs.gov/MedHCPCSGenInfo”
When no CCI edit is in place, it does not automatically mean that coders can report a particular code combination, nor does it mean that modifier 59 should be used.
The AMA writes the CPT coding rules with input from specialty societies like the AAOS. Medicare creates CCI edits on code combinations that require certain conditions to be met to be reported together and to override an edit when appropriate using modifier 59 (distinct procedural services). Depending on the CCI edits solely for coding guidance can actually create coding errors because Medicare expects the services to be accurately reported using CPT rules. And importantly, not all payors incorporate every CCI edit into their claims processing software.
Now, let’s go back to the coder’s scenario. A joint injection administered by the surgeon at the surgical site for pain management is an inclusive procedure and is not separately reportable by the operating surgeon or assistant according to the CPT rules and the AAOS Global Service Data Guidelines (GSDG).
The CCI edit of “1” with the code combination of 29881 and 20610 means the injection is reportable when administered in a different large joint during the same surgical session. The surgeon uses modifier 59 on 20610 to indicate the injection was done in the different joint and links the appropriate diagnosis (hence medical necessity) for this service at the other location.
All surgical procedures include pain management administered by the operating surgeon or assistant. The fact that Medicare has not placed a CCI edit in place with the 29806 (Bankart) and 20610 (major joint injection) does not mean they can be reported together, with or without the inclusion of a component code edit on the joint injection.
• Always code the case correctly based on CPT rules and the AAOS GSDG.
• You may consider “overriding” a CCI edit if the documentation supports all services the surgeon wishes to report and the CPT rules/GSDG support the reporting of the code combinations together.
• Do not use modifier 59 to override incorrect code combinations. For example, CPT code 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]) has a CCI edit allowing CPT code 23130
(Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release) to be “unbundled” from CPT code 23420. If the acromioplasty were performed on the same shoulder as the reconstruction of the rotator cuff, the acromioplasty is bundled according to the definition of the rotator cuff reconstruction. Overriding the edit with a modifier 59 is an incorrect use of the modifier.
• Code correctly and appeal wisely.
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 email@example.com