Medicare decision to treat pelvis as unilateral structure creates confusion

Have you received a denial from Medicare, stating that Category I Current Procedure Terminology (CPT) codes 27215–27218 are invalid? If so, you’re not alone.

In 2009, the American Medical Association (AMA) made changes to the CPT descriptors for those codes and to its coding guidelines to clarify that each of the surgical procedures was for the treatment of a unilateral pelvic injury. In the presence of bilateral pelvic injuries, these surgical treatments could be billed bilaterally.

The Centers for Medicare and Medicaid Services (CMS), however, in its 2009 Medicare Physician Fee Schedule, did not agree with the AMA CPT changes. This decision has and is continuing to cause confusion about coding pelvic fractures and dislocations.

In its opinion, Medicare stated that the pelvis is a single anatomic (ie, unilateral) structure. As a result, Medicare does not allow bilateral billing. Instead, Medicare created four new “G” codes (temporary national codes) to report and be reimbursed for pelvic surgical procedures, which would be considered as unilateral only.

The 2010 AMA CPT Manual includes the following instruction with codes 27215–27218: “To report bilateral procedures, report [27215–27218] with modifier 50.” Although this is correct coding for third-party payors, it is not correct coding for Medicare. Because Medicare does not recognize the bilateral modifier for these services, correctly coding these four procedures for Medicare beneficiaries requires that you use the G codes.

Here’s the rule: To code pelvic fractures correctly, use CPT Category I codes when billing non-Medicare payors and use Medicare’s temporary national G codes when billing Medicare.

Understanding the shift
Table 1 shows how the five-digit Category I CPT codes parallel the associated Medicare G codes. Note that Medicare added the terms unilateral or bilateral to the G codes, thus invalidating CPT codes 27215–27218 as valid codes.

It is important to understand how to read the Medicare fee schedule so that you can identify when a code is invalid. The ultimate tool for fast, easy, and accurate coding and cross-referencing is Orthopaedic Code X, which not only shows the code status of each code but also enables you to navigate, translate, and integrate all six critical coding databases.

In Fig. 1, the Code Status for CPT codes 27215-27218 shows that they are invalid codes for Medicare, and any claims submitted to Medicare using these codes will be denied.

If you submit a claim that is denied (Fig. 2), you need to pay attention to the Remittance Advice Remark Codes and the Claim Adjustment Reason Codes.

Remittance advice remark codes convey information about remittance processing or provide a supplemental explanation for an adjustment already described by a claim adjustment reason code. Each remittance advice remark code identifies a specific message as shown in the remittance advice remark code list.

Claim adjustment reason codes communicate an adjustment, explaining why a claim or service line was paid differently than it was billed. These are used only if an adjustment is made to a claim.

In Fig. 2, MA130 is a remittance advice remark code indicating “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”

MA15 is an alert advising you that your claim has been separated to expedite handling, and you will receive a separate notice for the other services reported.

N301 indicates “Missing/incomplete/invalid procedure date(s),” and the 96 indicates a noncovered charge(s). At least one remark code must be provided (it may be either the remittance advice remark code or the National Council for Prescription Drug Programs [NCPDP] reject reason code).

Next steps

• Update your charge capture tools and add the G codes for pelvic fractures being billed to Medicare only.
• Appeal any private payor denials of CPT codes 27215–27218 as invalid codes. Review contracts to determine if the payor has an inclusion statement related to Medicare temporary codes.
• Obtain instructions in writing from private payors who deny CPT code(s) 27215–27218 as invalid. Do not report the G code to private payors without written instructions.
• Monitor reimbursements closely. Although Medicare will reimburse each G code at 100 percent only when it is submitted as the primary procedure (regardless whether for a unilateral or bilateral fracture), you should expect 150 percent when reporting the management of a bilateral fracture to private payors.

Table 2

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 and edited 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