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1. Epidural injections
Significant reimbursement losses are inevitable when epidural and tendon sheath injection procedures are reported incorrectly. Improper reporting is often due to a lack of understanding of the Medicare edits and/or deficient operative report documentation.
While questioned by many providers, the Medicare CCI edits currently bundles CPT 62310, Injection, single not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s), epidural or subarachnoid; cervical or thoracic into CPT 20550, Injection(s);single tendon sheath, or ligament¸ aponeurosis (eg, plantar" fascia").
Medicare's correct coding modifier indicator (1) allows for a modifier (i.e., -59 when applicable) to be appended to CPT 62310 when performed at a separate and distinct anatomical location/region than the injection reported by CPT 20550.
According to the National Correct Coding Initiative, "Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier -59 and other NCCI associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used." Source: www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf (pdf)
Coding tip: When considering code determination, the physician's documentation should detail the specific injections and separate/distinct anatomic locations/regions he is entering and/or injecting as well as the medical necessity for each injection(s).
- If determined that detailed documentation does support separate/distinct injection procedures, two injection codes may be reported.
Correct code — CPT 62310-59 = $295.98; CPT 20550 = $19.30 approximate reimbursement by Medicare
- If determined that documentation does not support separate and distinct anatomic locations/regions for the two injections performed, only one injection can be reported.
Correct code — CPT 20550 = $19.30 approximate reimbursement by Medicare
Note: If documentation is deficient, it is strongly recommended to query the physician for clarification.
2. Platelet rich plasma injections
PRP is identified by Category III code 0232T (injection[s], platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed).
Coding tip: Beware! Category III code 0232T can only be reported if the PRP injection is performed on a nonsurgical site or when performed unrelated to the surgical site. CPT instructs not to report Category III code 0232T in conjunction with 20550, 20551, 20926, 76942, 77002, 77012, 77021 and 86965.
3. Medial branch blocks
Medial branch blocks are continually being over-reported as a result of the coder's confusion with spinal anatomy or the physician's operative procedure not being described in detail.
Take, for example, a procedural note stating and describing medial branch blocks of the L3, L4 and L5 nerves as being performed. Since L3, L4 and L5 medial branch nerves innervate the L4-L5 and L5-S1 facet joint, we would report two CPT codes (64493 and 64494 provided the injections were performed with fluoroscopic guidance or CT guidance) for two facet joint injections despite having injected three nerves. Remember, the code description is for a facet joint injection. (Aug. 2010 AMA CPT Assistant)
Coding tip: According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. Since each lumbar facet joint is innervated by two medial branches of the primary dorsal ramus, both must be anesthetized to completely block a single joint.
If a physician states he intends to inject three medial branch nerves and he injects the L3, L4 and L5 medial branch nerves, we would only report two facet joint injection codes despite three nerves being injected. Remember, two nerves anatomically innervate each facet joint. So, we only report two CPT codes, not three.
Documentation tip: Many physicians are very detailed in their operative report (descriptions and titles) to include "medial branch blocks L3, L4 and L5 nerves "at L4-5 and L5-S1 facet joints" with detailed reiteration found in the description of the operative report. The simple addition of "at L4-5 and L5-S1 facet joints" makes all the difference to the novice coder when backed up by a detailed description and will eliminate erroneous reporting.
4. Laminotomy (hemilaminectomy) vs. laminectomy — 63030 Vs. 63047
Both CPT 63030 and CPT 63047 may be reported independently of each other when performed during the same operative session pending clinical documentation.
CPT 63030, Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar (including open or endoscopically-assisted approach) normally bundles into 63047, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g. spinal or recess stenosis), single vertebral segment, lumbar. When determining separate reporting, ask the following:
- Does the specific carrier or Medicare edits allows for a modifier to be appended?
- If the specific carrier or Medicare edits allows a modifier, is the service separate and distinct from the primary procedure in this instance with clinical/op documentation describing the additional procedure in detail?
- Is Medical necessity supported for the additional procedure to have been performed?
Let's say a laminectomy, decompression of the spine, facetectomy of the L2 vertebra for spinal stenosis and laminotomy with excision of the intervertebral disk at L1 for HNP is performed.
Since clinical documentation details both a laminectomy and a laminotomy being performed on different levels of the spine with medical necessity clearly defined, both CPT code 63030 (L1 HNP) and 63047 (L2 spinal stenosis) may be reported with the appropriate modifier.
Sequence CPT codes according to your commercial carrier and append the appropriate modifier to CPT 63030 to indicate a separate and distinct procedure/level.
Reimbursement note: While Medicare edits allows separate reporting of these procedures when clinically indicated, neither CPT 63030 nor CPT 63047 are found on Medicare's ASC approved list of surgical procedures. This does not preclude that all commercial carriers follow Medicare's footsteps. Verify reporting/reimbursement policies for all carriers prior to performing these procedures at your facility.
5. Open rotator cuff repairs of the shoulder
Review CPT codes 23410-23412 to report open rotator cuff tear repairs (to include mini open rotator cuff tear repairs) with code selection determined by acute versus chronic conditions. Mini open rotator cuff tear repairs typically don't involve entry into the shoulder joint while the tear can still be visualized and repaired.
While CPT provides a parenthetical statement under CPT 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair), when directing the CPT user to report 23412 for mini open rotator cuff repair we still need to determine the final code selection based on the procedural description and whether the condition is acute versus chronic.
Coding tip: CPT code verbiage in 23410-23420 is specific for an acute versus chronic condition within its verbiage.
Documentation tip: The operative documentation should provide whether the patient has an acute versus chronic condition. If no indication is provided within the clinical documentation, CPT code determination cannot be made without physician query. To assume acute versus chronic will impact your facility's bottom line by roughly $150 for applicable Medicare accounts.
6. Colonoscopy with polypectomy
According to the AMA, "when used in a report, the term 'polypectomy' does not define the procedure used to remove the polyp. Additional information is needed to determine the proper CPT code. Polyps of various sizes can be removed using different procedures."
Let's look at the following operative excerpt:
There were no abnormalities noted except for a 5-mm sessile polyp noted in the proximal transverse colon. A polypectomy was performed with removal using forceps (45380? or 45384?). In the descending colon, a 4-mm polyp was biopsied (45380). Further withdrawal of the scope revealed internal hemorrhoids. The scope was then withdrawn. The patient was then transferred to the recovery room in a stable condition.
Physician query is indicated since the technique of the polyp removal is not detailed in the operative report. If the physician performed a cold biopsy forceps removal, only CPT 45380 is reported. If the physician performed a hot biopsy forceps removal (CPT 45384), then a total of two different techniques were performed on two separate polyps and both may be reported.
- If determined that a cold biopsy forceps technique was performed in the transverse colon, report CPT 45380 only once for the entire colonoscopy case. Both cold biopsy forceps technique performed in the transvers colon and the biopsied polyp in the descending colon are reported with the same CPT code 45380.
Correct code: (CPT 45380 = $380.23 approximate Medicare reimbursement)
- If determined that a hot biopsy forceps technique was performed in the transverse colon, report CPT 45384 in addition to the technique used for the biopsied polyp that was biopsied in the descending colon (CPT 45380).
Correct code: (CPT 45384 = $380.23; CPT 45380-59 = $380.23/2 approximate Medicare reimbursement)
Coding tip: If the physician performs and describes a colonoscopy with "biopsy" of a polyp, a query would not be necessary since CPT code 45380 indicates a colonoscopy with biopsy.
7. Arthroscopic knee synovectomy reporting
One of the biggest challenges in coding knee arthroscopies is determining whether to select CPT 29875 (arthroscopic synovectomy, limited,) or CPT 29876 (arthroscopic synovectomy, major, two or more compartments).
Let's say the physician performs an arthroscopic lateral meniscectomy and an arthroscopic two-compartmental synovectomy of the medial and lateral compartments of the right knee. It is incorrect to report an arthroscopic two-compartmental synovectomy, CPT 29876 in this case. The lateral synovectomy, CPT 29875, is inclusive in the lateral meniscectomy procedure reported with CPT 29881. Only the medial compartment will have a final synovectomy reporting of CPT 29875.
- Medial = 29875
- Lateral = 29875 + 29881 = 29881 (CPT 29875 bundles into 29881)
- Patellofemoral = n/a
The correct codes for the example listed above are 29881-RT; 29875-59 RT.
Let's say the physician performs an arthroscopic lateral meniscectomy and an arthroscopic two-compartmental synovectomy of the medial and patellofemoral compartments of the right knee. Because the medial and patellofemoral synovectomies are distinct from the lateral location, an arthroscopic two-compartmental synovectomy, CPT 29876 is supported.
- Medial = 29875
- Lateral = 29881
- Patellofemoral = 29875
The correct codes for the example listed above are 29881-RT; 29876-RT.
Coding tip: When reading the operative report description, follow the surgeon as he describes the procedures performed within each of the three compartments. Look at each compartment, then determine the overall code(s) for each individual compartment.
8. Anterior segment aqueous drainage device
While there are a few potential codes utilized for the reporting of aqueous shunts and devices, Category III code 0192T (Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach) is at the top of the list when it comes to denials due to lack of medical necessity.
According to CMS and many commercial carriers, 0192T may be considered medically necessary as a method to reduce intraocular pressure in patients with glaucoma where conservative methods/medical therapy has failed to control the intraocular pressure.
Medicare denials are being seen due to the lack of documentation that the procedure is performed to reduce intraocular pressure in patients with glaucoma. The facility may be coding the procedure and conditions correctly according to the operative documentation but the documentation is lacking in medical necessity for the condition of glaucoma.
Coding tip: Verify with individual commercial carriers and/or MAC/LCD policies for medical necessity requirements/conditions when reporting 0192T. For example, CMS currently considers ICD-9-CM series 365.10-365.15 open-angle glaucoma as medically necessary to perform Category III code 0192T. Your specific MAC may have differing documentation/medical necessity requirements.
Documentation tip: Operative documentation should support all conditions for which the procedure is being performed to include the condition of glaucoma when clinically warranted and that the intraocular pressure is not currently being controlled by medications/medical therapy.
9. Interbody cage(s)
Interbody cage fusion uses a hollow threaded titanium or carbon fiber cylinder to fuse two vertebrae together. The diseased disc is removed and an interbody cage(s) are placed in the opening where the diseased disc has been removed.
CPT +22851 (Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace) is not a "stand-alone" code and is commonly reported in addition to an arthrodesis procedure. CPT code +22851 is not intended to be reported per cage. This code is reported once per level regardless of the number of cages inserted per level. For example:
- Two metal cages at L3-L4 intervertebral space is reported with CPT +22851 x 1 as an add-on code to the main procedure performed.
- One metal cage at L3-L4 and one metal cage at L4-L5 intervertebral space is reported with CPT +22851 x 2 as an add-on code to the main procedure performed.
Coding tip: Some carriers may require a modifier when add-on code +22851 is reported more than once to indicate a separate and distinct application at a separate and distinct level.
10. Chondroplasty reporting (CPT 29877 vs. HCPCS Level II Code G0289)
Our last coding challenge comes with determining the reporting of CPT code 29877 vs. HCPCS Level II Code G0289 (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of another surgical knee arthroscopy in a different compartment of the same knee) when a meniscectomy if performed in a separate compartment from the chondroplasty.
Let's say an arthroscopic medial meniscectomy is performed with an arthroscopic lateral chondroplasty of the knee. Prior to code determination, the facility must be knowledgeable of the type of carrier (commercial vs. Medicare) for the account being reported.
If the account is a commercial account that follows AMA guidelines, we would report CPT codes 29881; 29877-59. Keep in mind, some carriers may differ from AMA guidelines allowing reporting/reimbursement for only CPT code 29881.
If the account is a Medicare account, we would initially consider CPT codes 29881; G0289. However, G0289, while on the Medicare ASC list of approved procedures, is listed with an N1 payment indicator. N1 indicates the reimbursement for G0289 is packaged into the reimbursement for the main procedure performed (meniscectomy) during the operative session.
The Medicare Claims Processing Manual states "ASCs should not report separate line-item HCPCS codes or charges for items that are packaged into payment for covered surgical procedures and therefore, are not paid separately." Facilities should follow billing guidelines for HCPCS listed as N1, since individual state ASC billing policies may differ in regards to dropping these HCPCS to a claim.
CMS does not allow substitution of G0289 with CPT 29877 simply to receive additional reimbursement.
Cristina Bentin can be reached at cristina@ccmpro.com. Learn more about Coding Compliance Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.