EM Coding Alert

Hint: The decision for a TKR may formulate over several visits.

If a provider decides that a patient requires a total knee replacement (TKR), the patient may need presurgical services, too.

The decision to perform a TKR is big, so find out how a provider comes to the decision, which diagnoses you may find associated with a TKR, and how to code every aspect.

You May See an Osteoarthritis Dx

Many TKR surgeries begin with the same condition.

“I’d say more than 90 percent of TKR cases are due to primary osteoarthritis. In some cases, I’ve seen osteonecrosis of tibia/ fibula, and an occasional severe fracture, such as the patella or tibia/fibula,” explains Ken Camilleis, CPC, CPC-I, COSC, educational consultant at Superbill Consulting Services in Quincy, Massachusetts.

The osteoarthritis of knee ICD-10 codes range from M17.0 (Bilateral primary osteoarthritis of knee) to M17.9 (Osteoarthritis of knee, unspecified). If you are coding a TKR, “there could be other injuries or diseases that warrant this procedure,” says Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, physician coding auditor/ educator consultant at MedKoder in Mandeville, Louisiana. When you are coding a TKR for another injury, make sure you check your payer’s policy on acceptable TKR diagnoses.

Track E/M and Imaging to Arrive at Surgery Decision

When a patient does need a TKR, the orthopedist makes that decision via a few different services.

Deciding to perform a TKR usually results from “a combination of E/M [evaluation and management] services after ordering and interpreting an X-ray,” Camilleis says. Sometimes, the provider will perform magnetic resonance imaging (MRI), or, rarely, a computed tomography (CT) scan to confirm the need for TKR, he says.

“When the patient’s everyday activities become limited by pain and stiffness, in conjunction with the imaging results, the orthopedist will decide surgery is needed to improve the patient’s situation. Typically, oral medication and injections are used to treat the patient prior to making the decision to perform surgery,” says Clements.

Remember: If the provider tries more conservative treatments before performing TKR — medications, injections, physical therapy (PT), etc. — take note in the medical record.

“Most insurance carriers are now requiring conservative treatment be performed prior to determining [TKR] surgery is needed. This can include cortisone or viscosupplementation injections, physical therapy, and bracing,” explains Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

Look to These Diagnostic Service Codes

Here’s a sampling of codes for services that your provider might perform to detect a patient who needs a TKR. This is

not a complete list; it’s possible, though not very likely, that your orthopedist will make a surgical decision using another diagnostic service:

E/M codes:

99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.)

X-ray:

• 73560 (Radiologic examination, knee; 1 or 2 views)
• 73562 (… 3 views)
• 73564 (… 4 or more views)
• 73565 (… both knees, standing, anteroposterior)

MRI:

• 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material)
• 73722 (… with contrast material(s))
• 73723 (… without contrast material(s), followed by contrast material(s) and further sequences)
• 73725 (Magnetic resonance angiography, lower extremity, with or without contrast material(s))

Once the orthopedist decides that a TKR is necessary, coding becomes a bit clearer. You will code nearly every TKR with one code: 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)).

This is the natural progression of services many will receive before TKR. “The [E/M] physical will ask questions to determine the severity of the pain and how it impacts the patient’s daily life,” explains Clements. “This information is used in conjunction with the results from the knee X-rays/ MRI to determine the extent of the wear and tear on the knee. The provider will try anti-inflammatories, physical therapy, injections,” or other conservative treatments before making the surgical decision.

Consider These Clinical Examples

Check out these clinical examples from Camilleis (Example 1) and Anderanin (Example 2):

Example 1:

A patient reports with right knee pain and effusion. The orthopedist has given the patient steroid injections to treat the knee previously, but the condition has reached the point where after the steroid has worn off, the pain and swelling is exacerbated. After discussing it with the orthopedist, the patient opts for surgery.

For the surgery, you’d report 27447-RT (Right side) with M17.11 (Unilateral primary osteoarthritis, right knee) appended.

Example 2:

A patient has osteoarthritis of the left knee and has had conservative treatment of PT and cortisone injections with no improvement of pain. A TKR is performed at the ambulatory surgery center (ASC).

For the surgery, you’d report 27447-LT (Left side) with M17.12 (Unilateral primary osteoarthritis, left knee) appended.