Orthopedic Coding Alert

A photographic record could be your answer to the nagging problem of receiving reimbursement for arthroscopic shoulder stabilization procedures. This is because these procedures have only "unlisted" codes that apply, and the visual evidence may be the only way to get paid.

"Arthroscopic surgeons are frustrated with the current codes," says William Levine, MD, an orthopedic surgeon and the director of sports medicine at Columbia Presbyterian Hospital, NY. Levine’s coders use 29909 (unlisted procedure, arthroscopy) for SLAP repair (repair of the proximal biceps tendon) and Bankart repair (repair of the glenoid labrum). And as for documentation, Levine explains, "I take photographs of every procedure." That way, when Levine’s coders are "fighting battles with insurers," they have an actual picture to submit.

Note: One orthopedic expert recommends keeping the photos on file for seven years.

Many surgeons are adding photos to their documentation when they perform arthroscopic procedures, one reason being that it’s so easy to add a camera to the set-up. Orthopedists need to take time up front to document precisely, including the surgical notes and the diagnosis to support medical necessity in order to get reimbursed for procedures that have an unlisted or unspecified code assigned.

Open Code is Not a Substitute

Code 23455 (capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation, with labral repair [e.g., Bankart procedure]) is for shoulder stabilization, but it applies only to open procedures. Still, that code can be useful for comparative purposes, according to Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, SC.

"The important thing is not to tweak the code. You are inviting trouble," says Callaway-Stradley. "Open procedure codes, such as 23455, should only be used when open procedures are performed. When a certain type of procedure category, such as arthroscopies, does not provide an adequate CPT code, it is not appropriate to pick the closest open procedure as a substitute. Not only does that contradict the basic premise of CPT coding but typically open procedures have higher values than their scope counterparts."

Although the editorial panel of the American Medical Association (AMA) charged with CPT code oversight can add a code, third-party payers assign a dollar value to each one. In the interim, comparisons with open procedures can help coders inform insurers that they are getting good value, whatever price they settle on for the unlisted procedures.

For example, in a 1998 study comparing open and arthroscopic Bankart procedures, F. Alan Barber, MD, of the Plano Orthopedic and Sports Medicine Center, Plano, TX, found total fees (including anesthesia and facility) were nearly 24 percent less for the arthroscopic than for the open procedure: That’s $4,474 compared with $6,062.

Documentation is as Crucial as Ever

Beyond the persuasive numbers, proper reimbursement depends on proper documentation. If there is fraying, how severe is it? How big an area is affected? The dimensions should be there in centimeters for any auditor to read.

And although surgery might seem synonymous with medical necessity, it’s important to document the need. Thus, the diagnosis code is crucial to reimbursement.

Diagnosis codes are key to medical necessity. In these situations ICD-9 codes 726.10 (rotator cuff syndrome of shoulder and allied disorders; disorders of bursae and tendons in shoulder region, unspecified) and 840.8 (sprains and strains of shoulder and upper arm; other unspecified sites of shoulder and upper arm) may apply to the surgery.

Time is also critical, especially when time has elapsed between the dislocation—or the first instability—in a shoulder and the surgery. Was it an accident, or a gradual deterioration? As always, the physician should be urged to complete the report in tandem with the procedure and not after time has passed and memory faded.

What if the surgeon tackles another procedure along with a SLAP or a Bankart repair? If there is a separate incision, it merits its own code. For example, partial claviculectomy (23120) would fall into the category of separate procedure. In these cases, modifier -51 (multiple procedures) during the same session must also be listed.

Persuading a surgeon to add details such as the extent of debriding and chondroplasty undertaken in the procedure might not be easy. But a record of both adds important documentation which will ultimately help in whether the claim is paid or denied.

 Thomas P. Obade, MD, author of "Tips for Proper Coding and Billing for the Orthopaedic Surgeon" (available at the Web site of the Arthroscopy Association of North America:  www.aana.org ) takes a dim view of unbundling, suggesting it will lead to trouble with insurers. He also cautions against "down-coding," noting it serves no useful purpose and might contribute to questions about quality of service. 

Catch-all codes, like the "unlisted" codes, are not ideal. They demand exact documentation, and they contribute to more interplay with payers, but for now, 29909 is the best code available for SLAP repair and Bankart repair.

Note: There were no changes to the arthroscopy section of the 2000 CPT, so it will be at least one more year before a better code will be an option.