Medicare Compliance & Reimbursement

What place does sports medicine have in Medicare?

Many orthopedists welcome CPT's new knee surgery codes with open arms, but some regard them as a dangerous diversion.

CPT 2005 will include no fewer than five new knee surgery codes, including autologous chondrocyte implantation (27412), osteochondral allograft (27415), arthroscopic osteochondral autografts (29866-29867) and arthroscopic meniscal transplantation (29868).

The latest arthroscopic additions perplex orthopedic trauma surgeon Paul Kosmatka with the Marshfield Clinic in Marshfield, WI. He sees them as part of a burgeoning trend of new arthroscopic and sports medicine codes that "are typically done on non-Medicare patients."

"Surgeons need to keep in mind that when they request new codes with associated higher RVUs, the 'new' RVU's have to come from somewhere," meaning that other orthopedic codes lose their RVU value, Kosmatka grouses. The surgeons requesting these codes won't feel the pain they cause unless they also treat a number of Medicare patients, Kosmatka adds.

But these codes aren't particularly sports medicine focused, and are more aimed at identifying new technology, counters Mary Brown with OrthoWest in Omaha, NE. She says new orthopedic technology often waits several years for a new code. She cites the example of arthroscopic rotator cuff repair, which finally gained CPT code 29827 after physicians had been performing the service for years. This procedure is more technically difficult to perform arthroscopically than in an open procedure, so it makes sense to give it higher RVUs.

Also, reducing procedures' RVUs over time as doctors become more expert makes sense. "The doctors have done [the procedures] for so many years that they're done very quickly," Brown explains. Once physicians have performed thousands of a particular procedure and its technology isn't new any more, it simply takes less time.

Physicians understandably feel concerned about a shortage of RVUs for new orthopedic codes, notes Brown. After all, the orthopedic section of the CPT contains more codes than any other.

General orthopedic surgeons as well as sports medicine physicians have been getting into performing knee arthroscopies, adds Margie Vaught, a coding consultant in Ellensburg, WA. And some younger disabled people also join Medicare, Vaught points out. Many of these people may have osteochondral defects and require allografts or autografts. Also, surgeons should remember that other payors besides Medicare use the CPT codes.