Orthopedic Coding Alert

Don't forget to send documentation with your 0054T-0056T claims Orthopedic practices increasingly use computer-assisted navigation to improve prosthesis alignment during arthroplasty procedures. But thanks to complicated coding guidelines and local regulations, confusion -- not reimbursement -- is on the rise.

Don't let your surgeon's computer-assisted navigation services trip up your claim submission process: Take heed of the following coding pitfalls to submit clean claims every time. Pitfall 1: Choosing the Incorrect CPT Code Much of the confusion over coding for computer-assisted navigation results from its Category III status. Category III codes are located at the back of the CPT book, and coders often overlook them and report an unlisted-procedure code instead of the appropriate -T- code:

- +0054T -- Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (list separately in addition to code for primary procedure)

- +0055T -- Computer-assisted musculoskeletal surgical navigational orthopedic  procedure, with image guidance based on CT/MRI images (list separately in  addition to code for primary procedure)

- +0056T -- Computer-assisted musculoskeletal surgical navigational orthopedic  procedure, imageless (list separately in addition to code for primary procedure). Temporary Category III codes are assigned to -emerging technologies, services, and procedures.- The designation is an important data collection tool for CMS. By assigning a Category III code to a new technology and requiring health professionals to use it, CMS can then better track the use of the procedure and its effectiveness, and evaluate its appropriateness as a Category I code.

CMS also points out that the Category III procedures, because they are being evaluated, do not carry CMS- endorsement of -clinical efficacy, safety or the applicability to clinical practice.-

Because many carriers have a hard time with Category III codes (whether because they consider the service -experimental- or because 0054T-0056T contain a pesky alpha character), keep a letter on file explaining the code and the need for the service, and know what other information they might require. This can save you time and increase success when fighting denials. Pitfall 2: Linking the T Code to a Noncovered Diagnosis Code The ICD-9 codes that indicate medical necessity for computer-assisted navigation vary dramatically between carriers -- and if you link a noncovered diagnosis code to the T code, you can be sure your claim won't make the grade.

Some carriers don't list more than a handful of covered diagnosis code for these services. Excellus Blue Cross/Blue Shield now lists only six ICD-9 codes as supporting medical necessity for computer-assisted navigation with musculoskeletal services, and only for hip or knee replacements.

The Excellus policy states, -Computer navigation technology is an adjunct to joint arthroplasty, and coverage for the arthroplasty is not affected by the investigational status of computer navigation devices.- However, Excellus determines coverage eligibility for this service on a case-by-case basis, [...]