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. 

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 citing the similarities.
 
In the KISS letter that Stout sends with unlisted-procedure claims, she spends as much or more time highlighting the differences between the codes as she does the similarities. "I keep the letter as short as possible, describe the procedure as simplistically as possible, and highlight the important differences as bullet points." Using the SLAP repair and Bankart as comparative examples, Stout points out the following differences, and why the SLAP repair is technically more demanding than 23455:
 

The procedure is performed arthroscopically and requires the technical skill of arthroscopic visualiza-tion at the superior aspect of the glenoid.
 

The insertion of fixation devices can be difficult to perform arthroscopically.

Since Stout estimates that the arthroscopic SLAP repair is 10 percent more difficult than the Bankart procedure, she requests 110 percent of the carrier's normal fee for the Bankart procedure. She also says the KISS letter should be signed by the surgeon, not the coder or office manager. Even if he or she does not write the letter, the surgeon should review it and determine its accuracy before sending.
 
For Medicare billing, use 29909 or whichever unlisted-procedure code is appropriate for the surgery (29909 would be used for an arthroscopic procedure) as the billed code, says Barbara J. Cobuzzi, CPC, MBA, CHBME, president of Cash Flow Solutions Inc., a physician practice billing company in Lakewood, N.J. "Put the corresponding open code, e.g., 23410, rotator cuff repair in Box 19 (of the HCFA 1500 form)," Cobuzzi says. "We bill 25 percent higher than the open code for the technical advancement compared to the open. I rarely have a problem when I submit to Medicare or commercial insurers."
 
Other pointers for using analogous codes include completing the "remarks" section of the HCFA 1500 form with as much information as possible to explain the procedure, even if some of this is repeated in the KISS letter. Since an unlisted-procedure code is liable to pend in processing or be rejected by insurance companies' computers, coders should stick with a strictly paper claim rather than an electronic claim.
 
When billing unlisted procedures with comparative codes, some offices report better luck by sending the paper claim the first time without attached (stapled) documentation and completing the "remarks" section of the form. On the first claim filing, many carriers often detach the documentation, which gets separated from the claim, and the practice is asked to submit this paperwork again. Rarely, payers will reimburse a claim that has no attachment, and the practice does not run into time limits while waiting to collect the additional documentation. 

Coders should encourage their physicians to inform them when they are contemplating new surgical techniques that have no CPT code. As a result of informing the coder in advance of scheduling the first case, there is time to develop a reporting strategy by:
 

Choosing the appropriate unlisted-procedure code.
 

Reviewing existing codes to select one for comparative purposes. Ideally this code should be for a surgical procedure on the same anatomic site (e.g., don't select a code from the hand surgery section for comparison with a foot procedure) with a similar degree of difficulty or goal.
 

Establishing a fee for the unlisted procedure.
 

Preparing a letter explaining the procedure and justifying the fee. If the procedure is likely to be deemed experimental or investigational by the carrier, gather a sampling of peer-reviewed articles attesting to the efficacy of the procedure.
    
 
With this information, write to the major payers to ascertain whether they will reimburse for the procedure and, if so, negotiate an acceptable payment.

Since no amount of preparation can stop every claim denial, coders need the tools for an occasional appeal of unlisted-procedure claims. To reduce the chances of having a claim pending endlessly or denied, make sure the appeal for increased reimbursement is made to the appropriate person at the insurance company. Stout says that for managed-care companies in particular that person is often a medical director.
 
Appeal methods are liable to vary from one carrier to carrier. "Have your staff contact each of your major payers to determine what the proper channels are for filing these claims," she says, "and make sure they follow up diligently to ensure timely payment."
 
If unlisted-procedure claims or claims for certain surgeries are being consistently denied, ask the insurance company what can be done to avoid these denials. The result may be a renegotiated contract or amendments to the payer contract that include payment for commonly performed unlisted procedures.
 
The last issue in the plan for billing unlisted procedures occurs if the carrier refuses to accept unlisted-procedure codes. When this is the case, carriers should provide the practice with alternative codes to submit, and they should do so in writing. Because payers are essentially asking you to submit an incorrect code for a procedure, their written statement that this is the code(s) they require will protect your practice in the event of an audit. Ultimately, there is never a 100 percent guaranteed payment method when it comes to insurance billing, so coders need to "test the waters" from carrier to carrier, see what works and go from there.