The Centers for Medicare & Medicaid Services (CMS) developed two types of code edits for claims submissions to prevent overpayment of overlapping, duplicate services reported. The two types of code edits include the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs). These code edits are in place to attempt to reduce the paid claims error rate for services. CMS owns the NCCI program and is responsible for all decisions regarding its contents.
The files for both code edits are housed on the CMS website and are listed as spreadsheets and PDFs. The spreadsheet columns are categorized by the Healthcare Common Procedure Coding System (HCPCS) or CPT code, Practitioner Services MUE Values, MUE Adjudication Indicator, and MUE Rational.
The CPT code for osteotomy, 28300, Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation, has historically been listed with a Practitioner Services MUE Value of one. The number listed for the MUE edit reflects the maximum units of services the code is allowed to be reported per claim line or on a date of service for reimbursement. It indicates that surgeons would only be reimbursed for one calcaneus osteotomy per patient on a date of service, even if or when two osteotomies were performed. The MUE Rational currently listed is CMS Policy. To address this lack of recognition for the work involved when more than one calcaneus osteotomy is performed, AAOS worked with the American Orthopaedic Foot & Ankle Society and the American Podiatric Medical Association to submit compelling documentation directly to CMS urging the revision of this MUE edit associated with CPT code 28300 to increase from one to two.
The rationale for this request is that it is often medically likely that two calcaneal osteotomies need to be performed at the same encounter, and there is no overlap in the surgical work required of the two procedures when this occurs. Some clinical scenarios demand that two different osteotomies of the calcaneus be performed at the same encounter to achieve adequate correction. The two osteotomies are typically performed at the anterior process of the calcaneus and posterior calcaneal tuberosity. These procedures are typically referred to in peer-reviewed literature as Evans (anterior process) and Koutsogiannis (posterior tuberosity) osteotomies. When performed at the same time, these procedures are typically performed to address pes planovalgus that needs to be corrected in more than one body plane. The two osteotomies are performed at two distinct locations. When both osteotomies are performed at the same encounter, there are two separate incisions, and two separate dissections are required. There is no overlap in the surgical work required with the two procedures.
Peer-reviewed literature also substantiates the medical necessity of performing the two separate procedures at the same encounter to address pathology that impacts patients’ ability to function. One documented example is when multiple calcaneal osteotomies are performed to address pathologic, flexible, adult-acquired flatfoot disorder.
CMS evaluated AAOS’ request. They agreed that two calcaneal osteotomies (28300) may need to be performed at the same encounter and decided to increase the NCCI MUE for code 28300 from one to two. The change will be implemented in a future edit update, forecasted for the second quarter. It is yet another victory for orthopaedic surgeons.
CPT is a registered trademark of the American Medical Association.
Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.