What to do when your claim is denied

This is the first in a series of articles updating previous AAOS Now coding articles. Since the original article was published in August 2013, the Centers for Medicare & Medicaid Services (CMS) has released specific instructions related to shoulder coding. This article addresses the implications of Medicare's coding and payment rule, as well as Medicare's National Correct Coding Initiative (NCCI) edits for Medicare Part B services and the Medicare Outpatient Code Editor (OCE).

The American Medical Association's (AMA) Current Procedural Terminology (CPT) coding rules for arthroscopic subacromial decompression remain unchanged, meaning that the coding and appeal recommendations are correct based on CPT. These rules apply to non-Medicare Part B payers, unless a payer also follows Medicare NCCI rules.

Most payers have internal payment policies specific to individual corporate guidelines and may incorporate some elements of NCCI. Typically, however, these payers do not follow NCCI in isolation. Hence, it is critical to report services to these payers according to the CPT rules or the payer's published edit system, similar to Medicare's NCCI edits.
In some markets, private payers deny payment for CPT code 29826—arthroscopic subacromial decompression—when it is reported with open shoulder procedures. These coding and appeal strategies should be helpful when reporting an arthroscopic subacromial decompression in the following situations:

• independent of an open shoulder procedure
• in conjunction with an open shoulder procedure such as a mini-open rotator cuff repair
• in conjunction with other arthroscopic shoulder procedures

Scenario #1
CPT code 29826 (arthroscopic subacromial decompression), may be reported in conjunction with an open rotator cuff repair (23412) and arthroscopic distal claviculectomy (29824). The surgeon accurately reports these procedure to a private payer as 23412, 29824-51, and 29826. Payment is denied for CPT code 29826. The payers claim that the AAOS previously published the correct code for the arthroscopic subacromial decompression as CPT code 29822 or 29823, denying the procedure as an invalid CPT code.

Discussion
If the surgeon has documented both medical necessity and performance of the procedures, the CPT codes are correct according to the AMA's CPT rules, due to changes in the coding for arthroscopic subacromial decompression.

CPT code 29826—Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)—was revised in 2012. Part of the revision was a definition change; the major revision was changing the code from a stand-alone code to an add-on code. However, 29826 may only be added on to certain codes, which are specified below.

Add-on codes may not be reported independently and may only be reported if an associated index or primary procedure code is also reported. In this scenario, CPT code 29824 is the index arthroscopic procedure, enabling the reporting of CPT code 29826.

Appeal rationale
The following rationale appeared in the 2012 CPT Changes: An Insider's View and can serve as official source documentation in constructing an appeal to non-Medicare Part B payers:

"To address the concerns of the AMA/Specialty Society Relative Value Service Update Committee (RUC) related to screening of codes that are performed together more than 75 percent of the time, code 29826, for reporting arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release, was converted to an add-on code. Code 29826 is billed more than 95 percent of the time with other arthroscopic repair of the shoulder codes. Therefore, it was decided that instead of relying on multiple procedure reduction rules, it would be better to convert 29826 to an add-on code. The codes that may be reported in conjunction with code 29826 are 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, and 29828. In addition, code 29826 was revised to more specifically delineate the structure involved, 'coracoacromial ligament (ie, arch),' and the preferred term 'when performed' was substituted in place of 'with or without.'"

In this scenario, CPT code 29826 is reportable because an arthroscopic distal clavicle resection (29824) was also performed. CPT code 29824 is an appropriate index or parent code for CPT code 29826. Because a second arthroscopic shoulder procedure was performed, CPT codes 29822 or 29823 (in place of 29826 for the subacromial decompression) would not be accurate coding.

Although this scenario shows correct CPT coding, Medicare NCCI edits exist between CPT code 23412 and 29826. Medicare considers the shoulder to be a single structure; thus, 29826 is considered to be a component of CPT code 23412 and cannot be reported to Medicare Part B when performed on the same shoulder, same session. A modifier may not be appended to bypass the NCCI edit. Remember, this is a Medicare Part B coding and payment rule. Report 23412 alone to Medicare Part B.

Scenario #2
CPT code 29826 (arthroscopic subacromial decompression) is billed in conjunction with an open rotator cuff repair (23412) and reported as 23412 and 29826 Payment is denied. The payers claim that the AAOS previously published the correct code for the arthroscopic subacromial decompression as CPT code 29822 or 29823.

Discussion
In this case, the payers are correct in recommending CPT code 29822 or 29823—so long as the arthroscopic subacromial decompression was the only arthroscopic procedure performed with the open rotator cuff repair. CPT code 23412 is not an appropriate index or parent code. The physician would report 23412 and then the appropriate limited (29822) or extensive débridement code (29823). This coding concept applies to all payers and is consistent with AMA CPT rules.

Appeal rationale
A second source for the appeal can be found in the April 2012 CPT Assistant. This article states that CPT codes 29822 and 29823 can be reported if the arthroscopic subacromial decompression was the only procedure performed (no index or parent code). The same concept would apply to this scenario if the only procedures reported are the open rotator cuff and the arthroscopic subacromial decompression.

The April 2012 CPT Assistant also addressed the following question: What CPT code(s) may be reported in the event arthroscopic subacromial decompression with partial acromioplasty is performed independent of any other arthroscopic shoulder procedure(s)?

The response was as follows: "Code 29822—Arthroscopy, shoulder, surgical; débridement, limited—or code 29823—Arthroscopy, shoulder, surgical; débridement, extensive—may be reported as appropriate when a subacromial decompression is done by itself. For example, if a subacromial decompression is performed alone, which usually involves débridement of soft tissue and bone removal, then code 29822 may be reported. If débridement of bone and soft tissue is performed, this code is correct and accurately describes the work done. If there is extensive work done in the removal of the soft tissue and bone, then one would report 29823."

Medicare agrees that in the absence of a parent or index arthroscopic code, CPT code 29822 or 29823 accurately reflects the work associated with the arthroscopic subacromial decompression and may be reported in place of CPT code 29826. However, CPT code 29826 cannot be reported with 29822 or 29823 in this scenario.

Next steps
To construct the appeal to non-Medicare Part B payers, take the following steps:

• Ensure that the operative note clearly supports the services performed.
• Accurately submit CPT codes in descending value order.
• List the add-on code, when present, subsequent to the index or parent code. For example, CPT code 29826 must be listed on the claim form subsequent to an arthroscopic shoulder index or parent code.
• Add appropriate modifiers to subsequent stand-alone procedures.
• Appeal denials using CPT source documents or AAOS Practice Management coding tips.
• On Medicare Part B claims, do not append a modifier 59 to bypass NCCI edits when an NCCI edit exists between the code combinations and the procedures are performed on the ipsilateral shoulder. If one of the procedures is performed on the contralateral shoulder, append the anatomic modifiers RT (right) and LT (Left) instead of the modifier 59.

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.