Published 9/1/2015
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Mary LeGrand, RN, MA, CCS-P, CPC
Physician members and staff attending AAOS-sponsored coding workshops frequently have questions that cannot be addressed in a course, or that surface after they return to the office. This month’s coding column addresses several questions that have been received after a coding workshop. In most cases, the question involves differences between the way Medicare and private payers use the American Medical Association’s (AMA) Current Procedural Terminology (CPT) codes.
Shoulder denials
Q: Can you explain why our Medicare carrier denies claims with codes for an open rotator cuff surgery (23412), distal clavicle resection (29824), and arthroscopic subacromial decompression (29826)? My staff tells me that CPT code 29826 is denied as incidental to CPT code 23412, and that we cannot appeal with a modifier 59 or an “X” modifier.
A: Your staff is correct if these procedures are performed on a Medicare patient. Although the code combination (23412, 29824, and 29826) represents correct coding according to the CPT rules, Medicare considers the shoulder to be a “single anatomic structure.” Under Medicare rules, a CPT code cannot be submitted with a modifier 59 if an NCCI (National Correct Coding Initiative) edit exists and the services are performed on the ipsilateral shoulder.
In this scenario, Medicare defines CPT code 29826 as a component of CPT code 23412. As a result, the arthroscopic subacromial decompression cannot be reported to Medicare (with or without a modifier 59) on the same shoulder as the open rotator cuff surgery.
Initially, Medicare NCCI edits applied to Part B Medicare claims, but in August 2002, edits were added to the outpatient code editor (OCE). In January 2006, all claims became subject to NCCI edits for both inpatients and outpatients.
Continue to report accurately coded services to private payers according to the American Medical Association’s CPT rules unless a contractual agreement allows the payer to process claims based both on internal payer edits and Medicare NCCI rules.
Meniscectomy, chondroplasty, and loose bodies
Q: I am a hospital-employed orthopaedic surgeon who codes all of my own cases and submits the billing sheet to the hospital coders for review and submission of my claims.
I recently performed an arthroscopic medial meniscectomy, tricompartmental chondroplasty, and removal of a 6 mm loose body from the lateral compartment via a separate portal. I submitted CPT codes 29881 and 29874-59 (this was not a Medicare patient). The hospital coders said I could not report CPT code 29874-59 for the loose body removal because I performed a chondroplasty in the same compartment.
I know I cannot report the chondroplasty (29877) because it is inclusive to the meniscectomy. Are the coders correct in saying that I cannot report the removal of a loose body (size greater than 5 mm and removed via separate incision/portal) because I also performed a chondroplasty in the same compartment?
A: This question is being asked with increasing frequency. The chondroplasty is not reportable, based on the code definitions for CPT codes 29880 and 29881.
The following two conditions must be met to report the removal of a loose body:
- the loose or foreign body must be larger than 5 mm
- the loose or foreign body must be removed via a separate incision or new portal
In this scenario, you met both rules, so CPT code 29874 is reportable in addition to CPT code 29881. Append modifier 59 to indicate that the loose body removal met the distinct procedure rules. If reporting to Medicare, the rules are met to report G0289-59 as the removal of the loose body was in a separate compartment (lateral) from the medial meniscectomy.
Medical decision making
Q: I recently documented a patient visit for an established patient during which I took a detailed history, conducted a detailed exam, and took the patient through low-complexity medical decision making. My office will not allow me to submit level 4 established patient visit (code 99214) because the medical decision making was “low complexity” even though a decision for surgery visit was made at this visit.
A: Neither CPT nor Medicare defines which two of the three key components (problem addressed, data reviewed, level of risk) must meet or exceed a level 4 evaluation and management (E/M) code for an established patient visit. Based on your detailed history and detailed exam, a level 4 established patient E/M code is appropriate. For example, a joint reconstructive surgeon has been treating a patient with osteoarthritis in the right knee. Conservative therapy has been unsuccessful in relieving pain or improving function. The last patient visit was 3 months ago. The surgeon performs a detailed history, conducts a detailed exam, and discusses surgery with the patient as the only remaining option. Both surgeon and patient agree to proceed.
The surgeon did not order or review any diagnostic studies at this visit. The medical decision making is low complexity, based on no new data (straightforward), an established problem worsening (low), and decision for surgery without risk factors (moderate). Based on CPT rules, a detailed history, detailed exam, and low complexity medical decision making supports a level 4 visit. The decision for surgery alone presents risk, and this decision is based on key elements identified during the history taking and physical exam.
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.