This month’s column addresses recent questions related to correct coding under the American Medical Association’s (AMA) Common Procedural Terminology (CPT) rules and the AAOS Global Service Data Guide (GSDG).

Shoulder Surgery
Q. My coder says that, effective Jan. 1, 2013, only one surgical CPT code can be submitted, even when two or more procedures are performed in the same shoulder.

I performed an arthroscopic rotator cuff repair, an arthroscopic distal clavicle resection, an intra-articular débridement of the labrum, a biceps tenotomy, and a chondroplasty. Based on what my coder says, all I can report is a rotator cuff repair. Is this correct?

A. This is a great question and reflects the confusion created by the release of the 2013 Correct Coding Initiative (CCI) Guidelines. Under AMA CPT rules, physicians must report all services performed—assuming the services reported are documented, medical necessity is supported, and the correct coding is used.

According to CPT rules and the AAOS GSDG, the rotator cuff repair code (29827) and the resection of the distal clavicle (29824) exclude the intra-articular débridement. All services are separately reportable and the modifier 59 is appended to the intra-articular débridement to indicate distinct, separate procedures performed in separate anatomic areas and via separate portals or incisions.

Note: Medicare has a CCI edit in place for débridement services performed at the same time as a distal clavicle resection. Débridement in the acromioclavicular (AC) joint is inclusive to the distal clavicle resection (same anatomic location) so, although an intra-articular débridement is generally separately reportable, débridement in the subacromial space, débridement of the rotator cuff, or débridement of the AC joint would not be separately reportable in this scenario. The use of modifier 59 appropriately identifies the débridement in a different anatomic area requiring additional portal /incisions for the procedure.

Joint Injections
Q. The surgeon performed a shoulder joint injection (20610) and an injection for lateral epicondylitis (20551) on the same day. The claim was submitted using modifier 51 (required by our Medicare carrier). Medicare denied the claim, stating that the tendon injection was inclusive to the major joint injection.

A corrected claim was submitted using modifier 59 and Medicare paid. Why would Medicare require modifier 59 when the procedures were obviously at different anatomic locations?

A. The injection for lateral epicondylitis is a stand-alone procedure, performed at a different anatomic location than the shoulder joint injection. However, Medicare has issued a CCI edit with this code combination, due to a pattern of abuse reflecting the injection of the anesthetic prior to the actual joint injection.

Because these codes represent, by definition, stand-alone procedures, modifier 51 is the most correct modifier. The use of modifier 59 is not based on a coding rule, but is due to a payer edit rule. Continue to report this code combination with a modifier 59 when the injections are performed at different anatomic locations and medical necessity supports both services.

E&M Services
Q. Our coding staff says that an evaluation and management (E&M) service performed on the same day as a minor procedure may no longer be separately reportable. What are the rules and when can the E&M be reported separately?

A. An E&M is reportable if it is a significant separate service. If the E&M does not meet the significant separate service requirement, it is not reportable. Different diagnoses are not required to report an E&M with a minor procedure on the same day. However, some physicians continue to always report an E&M on the same day, because they do not fully understand the rules of the “significant separate service” and why it is necessary.

When physician services are valued by the AMA/Multi-Specialty Relative Value Update Committee (RUC), they include pre- and immediate post-service physician and staff time. (For “minor surgical procedures,” this is usually 15 to 20 minutes in addition to the “skin-to-skin” procedure time.) For this reason, payers apply a requirement for significant separate services to approve payment for E&M services provided on the same day as the minor surgical procedure.

The following examples illustrate when the E&M meets the significant separate service requirement.

Report both the E&M and the minor procedure—A new patient sees the orthopaedic surgeon for evaluation of right knee pain. Based on the history of present illness, the physician obtains a full review of systems as well as past, family, and social histories. The physician examines both knees, assesses gait and station, performs a neurologic exam to assess sensation and reflexes, and checks the patient’s pulses.

Following the exam, the surgeon orders radiographs and interprets them himself. After reviewing all the information, the surgeon decides to inject the right knee.

In this scenario the surgeon may report the E&M service with a modifier 25, the major joint injection (20610), drugs as appropriate, and the radiographs, as appropriate, assuming all documentation requirements are met. The E&M service is more extensive than the evaluation associated with the knee injection alone.

Report the E&M or the minor procedure, but not both—The same patient returns 3 months later, complaining of increasing knee pain. The previous injection had provided significant relief, until the past week when pain began to increase. The patient denies any other real changes and any new injuries. No new radiographs are taken. Based on the history of present illness, the physician evaluates the right knee and decides a second injection is appropriate.

In this instance the E&M is not separately reportable because the work is not “unrelated” to the affected knee and no new problems were addressed. The surgeon can report either the E&M or the injection with drugs, but not both, because the value of the procedural service includes the inherent pre- and postprocedure E/M relating to the knee pain/injection.

Physicians must adequately document the additional E&M services they are providing because payers will require clear demonstration of the amount of time spent evaluating and managing the patient. Without clear documentation, physicians risk denials and clawbacks.

Tips
Ensure all work performed is documented and supported by medical necessity. Link diagnosis codes appropriately.

Report all services according to the CPT rules, using the AAOS GSDG as an adjunct coding guideline.

Avoid using Medicare CCI guidelines as the basis for all CPT code submissions; private payers may not follow CCI payment rules.

Medicare updates CCI edits every quarter. If services are reported according to the CPT rules and Medicare later reverses the edit, the physician may appeal for services denied while the edit was in place. If the services were never reported, they cannot be appealed.

Avoid using Modifier 59 inappropriately to override payer edits.

Report the E&M services with a minor procedure only when the E&M is a significant separate service. If not, report either the E&M service or the minor procedure, but not both!

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.