Published 6/24/2021
Michelle Abraham, MHA, CCS-P; Joanne S. Willer, CPC

AAOS Responds to NCCI Code Edit to Distal Radial Fracture and Carpal Tunnel Release

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to control improper coding and inappropriate payment in Medicare Part B claims. Updates to NCCI are made quarterly.

In December 2020, AAOS sent comments to NCCI regarding its proposed procedure-to-procedure (PTP) code pair edits scheduled for implementation as part of the NCCI version 2021 Q2 for a future release. The proposed correct coding modifier indicator (CCMI) of “1” would apply for the CPT code pair 25607, Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation, and code 64721, Neuroplasty and/or transposition; median nerve at carpal tunnel. NCCI is listing the standard edit rational as mutually exclusive.

AAOS and the American Society for Surgery of the Hand (ASSH) argued that although a carpal tunnel release (CTR) is done infrequently in connection with a distal radial fracture (DRF) open reduction and internal fixation (ORIF), they are separate procedures with different anatomic sites and most typically require a separate incision.

The distal radius is, by definition, proximal to the wrist. The open treatment of a DRF may be performed through the dorsal or volar aspect of the distal forearm. When the fracture is approached volarly, the flexor carpi radialis sheath is incised with the soft tissues retracted ulnarly. However, the median nerve is not “released” or “transposed,” but is merely identified and protected with retraction.

AAOS emphasizes that treatment of a DRF does not require extending the incision past the wrist crease into the palm. In addition, it would be risky because that type of incision requires meticulous dissection of important nerve branches. If a direct blow to the palm causes symptomatic compression to the median nerve at the same time as the traumatic wrist fracture, the exploration of the median nerve in the carpal tunnel with release is distinctly different work, with different anatomy and a different surgical approach. Code 64721, the release of the median nerve at the carpal tunnel, is performed in the palm through a volar approach, which is distal to the wrist crease. At no time during a CTR is the distal radius visualized or approached. If clinically significant median nerve pathology is documented that requires a CTR at the time of fracture treatment, it should be separately reportable and should be reimbursed.

Furthermore, the 2021 AAOS Global Service Data Guide for Orthopaedic Surgeons (GSD) publication does not list code 64721, Neuroplasty and/or transposition; median nerve at carpal tunnel, as excluded for code 25607, Open treatment of distal radial extraarticular fracture or epiphyseal separation, with internal fixation. AAOS strongly believes that these procedures may be performed in conjunction, reported and reimbursed separately, as one procedure is not inclusive of the other.

On Feb. 18, the decision to implement the PTP code pair edit was maintained by NCCI. AAOS and ASSH do not support a PTP edit of “1” for this code pair and contacted CMS and NCCI again for further clarification. The groups participated in a virtual meeting to discuss the specific detailed clinical rationale as to why and how these two procedures are not inherently included in one another. AAOS and ASSH representatives further explained that the procedures defined in codes 25607 and 64721 are used to treat two entirely distinct diagnoses in two different anatomic areas of the upper extremity. It was emphasized that retraction and protection of the median nerve during the volar approach to the distal radius do not constitute a “transposition” of the nerve.

Despite these arguments, on April 20, NCCI finalized the decision to implement a PTP edit with a modifier of “1” for the code pair 64721 with 25607. A modifier indicator of “1” signifies that the use of NCCI-associated modifiers may be reported to bypass the edit if the two procedures described by the two CPT codes are performed at separate anatomic sites or at separate patient encounters on the same date of service.

AAOS is disheartened at NCCI’s decision to move forward with the implementation of this erroneous code pair edit, which does not seem to be based on anatomy or clinical practice. It is important to note that when performing and reporting these procedures together (64721 with 25607), physicians may now need to append modifier 59, Distinct Procedural Service, to indicate the procedures are distinctly separate and should be reimbursed as such. Any denied or bundled claims can be appealed.

Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.

Joanne S. Willer, CPC, is the manager of coding and reimbursement resources in the AAOS Office of Government Relations. Questions can be directed to willer@aaos.org.