# Total knee with assist of MAKO



## Stott (Feb 18, 2017)

The hospital purchased a MAKO to assist in total knee replacements. Can additional codes such as 0055T or 20985 be used with 27447? These codes were given by the doctor.


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## hblakeman (Feb 26, 2018)

*Makoplasty*

I'm curious as well.  There is so much conflicting information out there, even from the manufacturer.  Did you find an answer?


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## AlanPechacek (Feb 26, 2018)

MAKO is a system by Stryker which brings the use of robotics into joint replacement procedures (knee and hip).  I have never used it nor seen it used, but it would be used intra-operatively to assist and guide the bone cuts of the femur, tibia, and probably the patella, so as to be as exacting and precise as possible allowing for the best possible prosthetic fit and alignment of the joint.  Since it is used during the procedure, it would fall into the category of code* 20985: Computer Assisted surgical navigation procedure for a* *Musculoskeletal Procedure, without images*.  It is "real time" use by the surgeon, but doesn't rely on X-ray imaging such as fluoroscopy, and this makes it different from other types of combined X-ray and computerized intra-operative guidance systems.
     The Code *0055T: Computer assisted surgical navigational orthopedic procedure with image guidance based on CT or MRI images* is different in that this applies to the preoperative evaluation and planning for a procedure, usually a TKR.  This is not intra-operative imaging or guidance.  In this, the CT or MRI studies are used to create "customized" instruments or bone cutting guides to be used in surgery to help with prosthetic fit and alignment.  If the preoperative clinical notes document that an MRI or CT was used to design and customize the instruments and guides for the planned procedure, then this code could be used.
     I don't know if the MAKO system is in any way involved, affected, influenced by the preoperative imaging or not, i.e. is the preoperative imaging study "downloaded" into the MAKO computer to help guide the procedure?  For what it is worth, they appear to me to be independent of each other.  Consequently, if both are done and documented, then both could be coded.

I hope this helps some.  This is "new stuff," particularly the MAKO system/technology.

Respectfully submitted, Alan Pechacek, M.D.


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## hblakeman (Feb 27, 2018)

*Thank you*

Thank you for that explanation.  Our docs do use it for pre-op imaging as well as intra-operatively for UKR and TKR surgeries.  20985 seems to pay hit and miss, but 0055T almost never pays.  AAOS did recommend still billing 0055T as it can be used more as a reporting/tracking code.  Again, thank you for your feedback.


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## Orthocoderpgu (Mar 1, 2018)

*MAKO gets denied a lot*

Our hospital purchased a Mako a few years ago. From my end it seems that this is denied quite a bit which is unfortunate since it probably helps to have a better outcome for the patient.


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## Diana2032 (May 16, 2018)

AlanPechacek said:


> MAKO is a system by Stryker which brings the use of robotics into joint replacement procedures (knee and hip).  I have never used it nor seen it used, but it would be used intra-operatively to assist and guide the bone cuts of the femur, tibia, and probably the patella, so as to be as exacting and precise as possible allowing for the best possible prosthetic fit and alignment of the joint.  Since it is used during the procedure, it would fall into the category of code* 20985: Computer Assisted surgical navigation procedure for a* *Musculoskeletal Procedure, without images*.  It is "real time" use by the surgeon, but doesn't rely on X-ray imaging such as fluoroscopy, and this makes it different from other types of combined X-ray and computerized intra-operative guidance systems.
> The Code *0055T: Computer assisted surgical navigational orthopedic procedure with image guidance based on CT or MRI images* is different in that this applies to the preoperative evaluation and planning for a procedure, usually a TKR.  This is not intra-operative imaging or guidance.  In this, the CT or MRI studies are used to create "customized" instruments or bone cutting guides to be used in surgery to help with prosthetic fit and alignment.  If the preoperative clinical notes document that an MRI or CT was used to design and customize the instruments and guides for the planned procedure, then this code could be used.
> I don't know if the MAKO system is in any way involved, affected, influenced by the preoperative imaging or not, i.e. is the preoperative imaging study "downloaded" into the MAKO computer to help guide the procedure?  For what it is worth, they appear to me to be independent of each other.  Consequently, if both are done and documented, then both could be coded.
> 
> ...



Hi Dr. Pechacek,

Thank you for such detailed clarification. My provider performed and partial knee makoplasty so I will be coding it as follows: 27446 in addition to 20985 for the intraoperative imaging but I have a quick question, can I also code S2900 for using the robotic surgical system? The description of this code reads: Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure). This code  has been classified with an "I"  status by Medicare and the description reads:  "Not covered by Medicare (Medicare uses another code for reporting of, and payment for, these services)". What would be your recommendation? Any type of input will be kindly appreciated.

Best,

Vanessa


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## JulianneG39 (Sep 1, 2019)

AlanPechacek said:


> MAKO is a system by Stryker which brings the use of robotics into joint replacement procedures (knee and hip).  I have never used it nor seen it used, but it would be used intra-operatively to assist and guide the bone cuts of the femur, tibia, and probably the patella, so as to be as exacting and precise as possible allowing for the best possible prosthetic fit and alignment of the joint.  Since it is used during the procedure, it would fall into the category of code* 20985: Computer Assisted surgical navigation procedure for a* *Musculoskeletal Procedure, without images*.  It is "real time" use by the surgeon, but doesn't rely on X-ray imaging such as fluoroscopy, and this makes it different from other types of combined X-ray and computerized intra-operative guidance systems.
> The Code *0055T: Computer assisted surgical navigational orthopedic procedure with image guidance based on CT or MRI images* is different in that this applies to the preoperative evaluation and planning for a procedure, usually a TKR.  This is not intra-operative imaging or guidance.  In this, the CT or MRI studies are used to create "customized" instruments or bone cutting guides to be used in surgery to help with prosthetic fit and alignment.  If the preoperative clinical notes document that an MRI or CT was used to design and customize the instruments and guides for the planned procedure, then this code could be used.
> I don't know if the MAKO system is in any way involved, affected, influenced by the preoperative imaging or not, i.e. is the preoperative imaging study "downloaded" into the MAKO computer to help guide the procedure?  For what it is worth, they appear to me to be independent of each other.  Consequently, if both are done and documented, then both could be coded.
> 
> ...


The CDR, aka lay description for CPT 0055T does state preoperative images taken, as you suggested.  It goes on to further state:
*0054T-0055T* (
	

	
	
		
		

		
			





0054T, 
	

	
	
		
		

		
		
	


	




0055T)
Computer-assisted musculoskeletal navigation techniques are used with many orthopedic procedures, especially for accurate placement of the acetabular component during hip replacement surgery. Preoperative images of patient-specific bone geometry are first obtained for the surgical plan in whatever imaging modality is to be used. The patient-specific surgical plan and images are used during surgery to guide the surgeon by combining these with intraoperative navigation capabilities. Optical targets, or trackers, such as digitizing or LED-equipped probes, are attached to points on the bone anatomy or to surgical tools. An optical camera tracks the position of these for accurate navigation and measurement in relation to any bone or instrument movement as the surgery is performed. The software in these navigational systems matches or "registers" the position of the patient on the operating table to the geometric description of the bony surface derived from the images already used to plan the surgery. Multiple images are simultaneously displayed on the monitor. The "virtual" tool trajectory that corresponds to the tracked tool movements is displayed over the previously saved views in real-time as the surgeon operates. These are add-on codes to be used in addition to the primary procedure. Report 0054T for image-guidance based on fluoroscopic imaging and 0055T for CT/MRI imaging. If CT and MRI are both performed, 0055T is reported only once.

I would interpret this description to be stating 0055T includes an intraoperative component, as it says "as the surgery is performed". However, the key is it requires that imaging occurs with CT or MRI. I am not sure if MAKO qualifies as that.


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