Orthopedic Coding Alert

Choosing analogous codes to accompany claims for unlisted procedures, i.e., 29909 (unlisted procedure, arthroscopy), is often difficult. Selecting the right comparative code involves a careful analysis of code options and the familiar coding mantra: Document, document, document.
 
Orthopedic coders, perhaps more than those in any other specialty, are familiar with the reimbursement problems associated with unlisted-procedure codes. Code 29909 alone is routinely submitted to describe an array of arthroscopic procedures that have no CPT codes, from SLAP repairs to rotator-cuff repairs, to newer procedures like thermal ACL shrinkage. While many carriers instruct practices to bill using these codes, submitting 29909 (or other unlisted-procedure codes) alone might not be sufficient documentation to ensure reimbursement.
  
For that reason, orthopedic coders are increasingly turning to analogous codes to boost reimbursement. By submitting with documentation a code that is similar to the procedure performed, the complexity and amount of work involved in a procedure can be better conveyed to the claims adjuster.
 
One dictionary definition of the word analogous is: similar in some respects, allowing an analogy to be drawn. This definition supports choosing an analogous code to accompany unlisted-procedure claims. The code does not replace the unlisted-procedure code, but it allows an analogy to be drawn so the claims adjuster can look at existing RVUs since unlisted procedures have no RVUs and better determine payment. In an example from the March 2001 Orthopedic Coding Alert, a coder billed for an arthroscopic superior labrum anterior/posterior repair (SLAP repair) using 29909, but included a KISS letter that drew comparisons to a Bankart lesion repair (23455, capsulorrhaphy, anterior; with labral repair [e.g., Bankart procedure]). Because the Bankart has a CPT code with associated RVUs, the coder is both establishing a basis for reimbursement and providing justifying the fee. 

Choosing the Right Analogous Code
Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., says there is no exact formula for calculating the level of complexity of a surgical procedure for which no CPT code exists. "This is unfortunate," Stout says, "as so many orthopedic procedures that were once performed via open incisions are now accomplished arthroscopically." Stout advises her physicians to stay within the range of a 10 to 30 percent increase in fees for a procedure performed arthroscopically that is more complex than if it were performed open. 
Highlight the Differences
Using a comparative code to show similarities to an unlisted procedure may guarantee payment at a similar level as that comparative code. But when an unlisted procedure is more difficult than the analogous code, the practice will expect more reimbursement. Therefore pointing out the differences between the two codes is as essential if not more so as [...]