It’s time to test your knowledge! Before you read the answers to the following questions, ask yourself what you would do. Then check your response against the answer.

Excision of osteophytes with revision TKR
Q. The new joint reconstructive surgeon performed his first revision total knee replacement (TKR). He dictated that he removed several osteophytes and he wondered what Current Procedural Terminology (CPT) code to use to report this work. He suggested CPT code 27487 for the revision of both components. We have found a couple of codes for excision or curettage of bone on the femur and tibia, but we are not sure they are correct. Can we report the CPT codes for the curettage or excision to cover the osteophyte removal?

A. No. According to the AAOS Complete Global Service Data for Orthopaedic Surgery (GSD), “local bone graft and fixation for local bone defects or cysts” is included in CPT code 27487 (revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component). GSD also includes the following specific inclusions to CPT code 27487 (note #14, which applies to this situation):

12. partial or complete synovectomy (eg, 27334, 27335, 29875, 29876)
13. removal of loose bodies (eg, 27331, 29874)
14. debridement of knee with removal of osteophytes (eg, 27360, 27443, 29877)
15. internal fixation
16. release, repair, or reconstruction of ligament or capsule (eg, 27405, 27407, 27425, 27435)
17. manipulation of knee (eg, 27570)
18. removal of previously inserted prosthesis (eg, 20680, 27488)
19. arthrotomy of knee (eg, 27330)

Osteotomy of the ulna
Q. Our surgeon performed an osteotomy of the ulna and documented internal fixation. She wants to report using CPT code 25360. Does that code cover the internal fixation as well?

A. Yes, CPT code 25360 (osteotomy; ulna) includes internal fixation as an integral part of the procedure. This work does not have a separately reportable CPT code. If the procedure was performed for malunion of fracture, it might be advantageous to use 25400 (repair of nonunion or malunion, radius or ulna; without graft).

Denials for J3490
Q. Since the U.S. Food and Drug Administration approved the use of the drug Monovisc®, we have used J3490 to report its administration. We have always been paid, but have recently begun receiving denials due to an “invalid code.” How do we appeal these denials?

A. In 2014, you were correct to report J3490 (unlisted drug code). However, in 2015, the Centers for Medicare & Medicaid Services (CMS) released a new code—J7327 (hyaluronan or its derivative, Monovisc, for intra-articular injection, per dose). Note that this is a per dose code. Submit a corrected claim using the new J code.

Insufficient documentation
Q. Our sports medicine surgeon submitted an operative note for an arthroscopic rotator cuff repair and an arthroscopic subacromial decompression. We received payment for the surgeon, but payment for the physician assistant’s services was denied. We appealed and submitted the operative note for review. The payer responded by reversing the payment for the subacromial decompression due to insufficient documentation! When we reviewed the operative note, the procedure title stated that the surgery was an “arthroscopic subacromial decompression” and the surgeon documented that “…next, an arthroscopic subacromial decompression was performed” in the body of the operative note. We are unsure how to write the appeal.

A. To report any services to the payer and to select the appropriate CPT code, the surgeon must document the actual work performed to complete the procedure. Restating the procedure title in the operative note does not describe the work that is considered inclusive to the definition of the code. Documentation describing the procedure performed should include the key portions of the procedure.

The clinical vignette for CPT code 29826, which can be found in the American Medical Association’s (AMA) Code Manager® Online: Professional, provides a guideline for describing the performance of an acromioplasty. The technique described is not the only one that may be used, but the following description shows the depth of documentation required:

“The subacromial bursa is accessed via the posterior portal which reveals some fraying of the coracoacromial ligament accompanied by a bursal-side partial thickness rotator cuff tear. A lateral arthroscopic portal is developed and bursal tissue and the bursal side cuff are debrided for visualization. The coracoacromial ligament is released with a radiofrequency device. The arthroscope is placed in the lateral portal and an acromioplasty is performed using a bone-block technique from posterior to anterior with a motorized bone-cutting shaver. Hemostasis is obtained with a radiofrequency device.”

Arthroscopic shoulder procedures
Q. Our shoulder surgeon wants to know whether CPT codes 29806 (capsulorrhaphy) and 29807 (SLAP repair) can be billed together with the right documentation and perhaps the right modifier. The coders say no.

A. There is good reason for confusion here. This is an excellent example of correct coding according to the AMA CPT rules and the GSD. However, Medicare payment rules are different.

The CPT rules state that CPT codes 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy) and 29807 (repair of SLAP lesion) are separately reportable when, as you say, documentation and medical necessity are present. The AAOS GSD indicates that the work of each procedure—when performed for medical necessity and supported by documentation—is not inclusive to each other.

However, CMS payment rules show a National Correct Coding Initiative (NCCI) edit for CPT codes 29806 and 29807. These rules state: “CMS considers the shoulder joint to be a single anatomic structure. An NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder joint procedures should never be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder joint. This type of edit may be bypassed only if the two procedures are performed on contralateral joints.”

Remember, CMS NCCI payment rules are written for Medicare services, as noted in the NCCI Introduction section, and should not be automatically applied to all payers. The AMA and the AAOS support the reporting of both services as correct coding. Both 29806 and 29807 should be reported with the 59 modifier appended to the lesser code (29807). Because CMS defines the shoulder as a single organ system, it will not allow CPT codes 29806 and 29807 to be reported together with a modifier to bypass the edit.

Action steps

• Code correctly according to the AMA CPT rules and AAOS GSD.
• Learn the payer-specific rules for each payer and apply them appropriately.
• Don’t assume all payers follow Medicare payment rules.
• Review payer contracts to determine whether your practice has agreed to allow a private payer to process claims using both the payer’s internal edits and Medicare’s NCCI rules.

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.