The following coding questions have been raised during the past several months.
Removal of spinal interbody device
Q. In the operative note, the surgeon documented removal of an interbody device from L4-5. The surgeon states that a peer told him to report this procedure using CPT code 22850—removal of posterior nonsegmental instrumentation (eg, Harrington rod). The coding team does not agree. Is this work reportable and, if so, is CPT code 22850 the correct code?
A. The removal of an interbody device does not have a specific CPT code. It is not appropriate to use CPT code 22850 for this procedure. Nor should CPT code 22855—removal of anterior instrumentation—be used for the removal of an anteriorly placed intervertebral device.
Typically, this work for removing an interbody device is part of a more extensive procedure such as revision of an anterior interbody arthrodesis or a revision interbody fusion; the CPT code for that procedure is the one that should be reported.
Intraoperative nerve monitoring
Q. A recent review of aged accounts receivable found several denials for CPT code 95940—continuous intraoperative neurophysiology monitoring in the operating room, one-on-one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary procedure). The surgeon’s operative notes document monitoring using somatosensory evoked potentials, but do not include any specific times. The spine surgeon wants to know if the claims are being denied because the time is not documented.
A. The issue isn’t the time documentation—it’s the surgeon. Intraoperative nerve monitoring is not separately reportable by the operating surgeon. The rationale is that the surgeon cannot do both the surgery and the monitoring simultaneously. A guideline clarification in CPT 2013 states the following:
“Codes 95940 and 95941 describe ongoing neurophysiologic monitoring, testing, and data interpretation distinct from performance of specific type(s) of baseline neurophysiologic study(s) performed during surgical procedures. When the service is performed by the surgeon or anesthesiologist, the professional services are included in the surgeon’s or anesthesiologist’s primary service code(s) for the procedure and are not reported separately.”
Intraoperative nerve monitoring by the operating surgeon has never been separately reportable. The work associated with this activity is valued into the spinal procedure. For more information on this issue, refer to the “2013 Orthopaedic-Related CPT Code Updates,” in the December 2012 issue of AAOS Now.
Modifier 59 denials
Q. The local Medicare carrier has recently denied multiple claims with the same CPT code reported more than once, using modifier 59 to indicate that the second procedure was performed at a different location. For example, the surgeon performed an open reduction internal fixation of multiple metacarpal fractures. We reported 26615 once, and 26615-59 for each of the other fractures. Medicare paid the first code (26615) and denied the others as duplicates. How should this situation be reported?
A. Many local Medicare payers specify that modifier 59 should not be appended to a CPT code that is reported more than once. Instead, they require the use of modifier 76, (repeat procedure or service by same physician or other qualified healthcare professional). A corrected claim can be submitted, appending modifier 76 to CPT code 26615 for each of the other procedures to indicate that the same procedure was repeated at multiple different locations.
Continue to append modifier 59 for private payers according to the CPT definition for this modifier (separate site).
27686 versus 27685
Q. The pediatric orthopaedic surgeon recently lengthened two tendons in the same leg via the same incision. Should CPT code 27686 or CPT code 27685 be used to report this surgery?
A. This is a common question because the definitions of the codes are confusing. CPT code 27685 is defined as “lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)” and is reported when the surgeon shortens or lengthens a single tendon. This is a “separate procedure” code and may be reported only if the sole procedure performed is the shortening or lengthening of a tendon or if only a single tendon is shortened or lengthened via a single incision. (For more information, see “Separate Procedure” in the CPT section titled “Surgery Guidelines.”)
CPT code 27686 is defined as “lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each.” This code is reported when the surgeon lengthens or shortens multiple tendons via the same incision as described in the question. In this scenario, 27686 and 27686-59 should be reported under CPT rules to indicate that two tendons were lengthened through the same incision.
Arthroscopic OCD lesion
Q. The surgeon documented an arthroscopic procedure for treatment of an osteochondritis dissecans (OCD) lesion in the elbow. Because no CPT code can be found for this procedure when it is performed in the elbow, can the code used to report OCD treatment in the knee or ankle be used?
A. No, using a code from the knee or ankle is not appropriate for reporting a surgery performed in the elbow. The correct way to report this procedure is to use CPT code 29999—unlisted arthroscopic procedure. CPT instructions are clear in regard to avoiding the use of codes that only approximate a service, and state: “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service 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.