Challenges in Orthopedic Coding Become 'Three Easy Pieces' With Expert's Help

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Mary LeGrand, RN, MA-CCS-P, CPC, a consultant with KarenZupko & Associates in Chicago, discusses the following three orthopedic coding challenges.

1. Coding for arthroscopic reconstruction of anterior cruciate ligament (ACL) surgery. ACL surgery is defined by CPT 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction). This CPT code is valued to include the harvesting and placement of a graft.

Here are some key documentation issues to consider when reporting an ACL reconstruction.

1. It is not uncommon in these cases to have an assistant surgeon or assistant at surgery, such as a PA. If the assistant will be reporting their services to the payor, the surgeon should document the name of the assistant, explain the medical necessity for having the assistant in on the case and describe the work the assistant performed. Typically the surgeon does this in preparation of the graft.
2. There are several tendons available for grafting. If the tendon is harvested from the same extremity, the harvest is included in the definition and payment for the ACL code 29888. If the tendon is harvested from the contraleral extremity and documentation of medical necessity is present, the surgeon may additionally report CPT code 20924 (Tendon graft, from a distance, such as palmaris, toe extensor, plantaris), appended with modifier -59.
3. There is no CPT code for the reconstitution of tendon allograft. The work associated with this is included in the payment for CPT 29888.
4. There is no CPT code for a revision ACL. If the surgeon performs a revision ACL and encounters significantly more work due to scar tissue, removal of grafts or hardware, the surgeon may consider appending modifier -22 to indicate the increased procedural service. Documentation of the additional physician's work must be very specific — significantly above and beyond the work associated with a primary ACL reconstruction.

2. Bundling injection codes by payors. Medicare has a CCI edit in place with the transforaminal epidural injections and trigger point injections. If the surgeon performs these two services at distinct separate locations, documentation of medical necessity exists for both procedures and the work is clearly detailed in the procedure note, the surgeon may report both services. A modifier -59 is appended to the trigger point to indicate a distinct separate location from the transforaminal epidural injection.

3. Two separate surgeons for anterior lumbar surgery. When a vascular surgeon performs the surgical approach for an anterior lumbar interbody fusion (CPT 22558), the vascular surgeon and the spine surgeon become co-surgeons for the fusion. Each surgeon dictates their own surgical procedure in a separate operative note outlining their part of the procedure.
In an L4-5 anterior lumbar interbody fusion, both surgeons report CPT 22558-62 for the fusion part of the procedure. If the vascular surgeon remains scrubbed in on the case and assists with instrumentation and or grafting, they will report the appropriate CPT codes defining the additional procedure with the appropriate assistant at surgery modifier, either -80, -81 or -82.

For example, the spine surgeon performs a L4-5 interbody fusion, places an anterior plate L4-5 and then places a polyetheretherketone (PEEK) interbody cage. So the spine surgeon would report CPT 22558-62, 22845 and 22851.

Meanwhile, the vascular surgeon performs the approach and then assists on the remainder of the case. So the vascular surgeon reports CPT 22558-62, 22845-80 and 22851-80, assuming that modifier -80 is appropriate.

Both surgeons are reimbursed 62.5 percent of the allowable for CPT 22558. The spine surgeon expects 100 percent reimbursement on 22845 and 22851. The vascular surgeon expects 16 percent of the allowable for CPT 22845-80 and 22851-80.

Learn more about KarenZupko & Associates at www.karenzupko.com.

The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.