Published 5/1/2013
Mary LeGrand, RN, MA, CCS-P, CPC

A Potpourri of Coding Questions

This column addresses recently asked questions on coding orthopaedic procedures. Remember, you can direct specific coding questions to the AAOS for review by the Coding, Coverage, and Reimbursement Committee and AAOS staff. Visit www.aaos.org/coding for more coding information.

Postoperative period services
We are a new practice and our coders are new to orthopaedic surgery coding. After reading
“Surgical Modifier Application during the Global Period” (AAOS Now, March 2013), we researched our private payer contracts and found that they all follow Medicare’s surgical package rules. After a joint reconstruction, we have been billing for a joint injection for pain management or aspiration of an effusion in the operated joint with a modifier 58. Is this correct? Can you help clarify this scenario?

A: After joint reconstruction, joint injections for pain management and aspiration of an effusion in the operated joint are not considered separately reportable by Medicare. These are considered to be follow-up care during the global period, unless the patient is returned to an approved operative suite. This scenario does not meet the intent of modifier 58 because neither the joint injection nor the aspiration meets the staged or planned procedure definition.

VEPTR insertion
The pediatric spine surgeons perform a procedure they call “VEPTR.” From the operative note, it appears that they are placing instrumentation only without any associated fusion. How do we report this procedure?

A: VEPTR stands for “vertical expandable prosthetic titanium rib.” It is used to treat thoracic insufficiency syndrome, a congenital condition in which severe deformities of the chest, spine, and ribs prevent normal breathing and lung growth and development. The insertion is reported with an unlisted spine code, 22849.

Meniscal repair and meniscectomy
The results of our internal coding audit surprised our surgeons, who learned that they cannot report a chondroplasty with a meniscal repair when the chondroplasty was performed in a different compartment. They were under the impression that only the meniscectomy included the chondroplasty. The audit stated that Medicare has a “zero” modifier with the 29877 code, indicating that the meniscal repair also includes the chondroplasty.

A: Congratulations on performing an internal audit! Your question raises several concerns. Be sure to follow CPT coding rules and the AAOS Complete Global Service Data for Orthopaedic Surgery when reporting all services. Medicare payment rules are specific to payments and occasionally require the use of a different code when reporting services.

The meniscectomy codes (29880 and 29881) do include a chondroplasty, regardless of compartments. But the same concept does not apply to meniscal repairs (29882 and 29883). For private payers, who should be applying CPT rules, you should report the meniscal repair and the chondroplasty code 29877 with modifier 59 appended when the chondroplasty is performed in a different compartment than the meniscal repair.

Medicare does have a zero modifier for CPT code 29877. But if the chondroplasty is performed in a different compartment, Medicare instructs the physician to report G0289.

Continue to review coding practices and ensure that all physicians, nonphysician providers, and staff are up-to-date on the coding rules.

Multiple metacarpal fractures
Can we report CPT codes 26615 and 26605 when a patient has multiple metacarpal fractures and the physician manages the fractures in the same session? In a recent multiple trauma case, the patient had a displaced metacarpal fracture requiring an open reduction internal fixation (ORIF), a nondisplaced metacarpal fracture, and other fractures. A splint was applied after the ORIF procedure to stabilize both fractures.

A: AMA CPT rules describe codes 26615 and 26605 as follows:

  • 26615—Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone
  • 26605—Closed treatment of metacarpal fracture, single; with manipulation, each bone

Note that in each description the instructions are to report the procedure code for “each bone.” Your scenario, as described, would be reported with 26615 and 26605-59. Modifier 59 would be appended to the lesser-valued procedure (26605) to indicate that the nonmanipulative treatment of the fracture is for a separately identifiable bone.

Podiatric bone graft
The podiatrist in our office recently performed an arthrodesis procedure that required bone graft to be harvested from the iliac crest. The podiatrist requested the orthopaedic surgeon to harvest the graft. The arthrodesis code does not include the harvest of bone graft in its description so I don’t think this is cosurgery. How does the orthopaedic surgeon report the bone graft? The orthopaedic surgeon did not assist on any part of the procedure other than the associated bone graft work.

A: The surgeon reports the appropriate bone graft code—20902 for a large bone graft or 20900 for a bone dowel—depending on the work performed. The podiatrist reports the appropriate arthrodesis procedure code.

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

If you have questions about coding or want to suggest a topic for a future coding article, email aaoscomm@aaos.org