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, so you should submit a letter from the surgeon with your claim outlining the necessity of the computer-assisted navigation tool.

Tip: -With my claim, I send a letter I drafted up that talks about the navigation and how it allows the surgeon to simultaneously visualize two- or three-dimensional views of the patient's anatomy on a monitor,- says Sandra Burnett, billing supervisor at Orthopaedic Associates of Saratoga in Saratoga Springs, N.Y. -I also include how this technology can provide for near-perfect alignment, which will make the implant last longer, possibly shorten recovery time, and reduce insurance costs.- Burnett has had success collecting from Medicare, Tri-Care and United Healthcare for these procedures.

Pitfall 3: Assuming Your Payer Doesn't Cover It

Because computer-assisted navigation is considered investigational by CMS, many practices assume that all Medicare carriers will deny these services, but that is
not true.

-I-m in Pennsylvania and our Medicare carrier allowed payment for computer-assisted navigation starting in 2006,- says Patrice Young, CPC, CMSCS, coder at Commonwealth Orthopaedic Associates Inc.

In fact, Pennsylvania's Medicare carrier (Highmark) included payment amounts for these codes on its 2006 fee schedule. The amounts varied according to geographic location, but payment for 0054T was about $350, payment for 0055T was about $400, and 0056T paid about $305.

Pitfall 4: Failing to Document the Procedure Accurately

Even if your carrier allows reimbursement for computer-assisted navigation, reimbursement can still be an uphill battle. You should send a detailed operative report with your claim to clearly document medical necessity.

Send your documentation: -The physician who uses the device in our practice is very explicit with his op note and covers the ins and outs of the procedure,- Young says. -I send the op notes with my claims.- If a particular payer denies the procedure as experimental, Young writes off the fee, but if it's denied for other reasons, she appeals the claim and sends it back for peer review so that an orthopedic contact at the insurer can review it for possible reimbursement.

In addition to sending the op report and a letter with your claim, you may want to bolster your reimbursement odds with additional literature. -I also include the page from the CPT manual that shows 0056T is an add-on code and that the Category III codes are for emerging technology, not investigational procedures as some insurance companies try to state,- Burnett says. -I send a page from the NCCI Manual to show that 0056T is not included in the total hip or knee replacement, and I also submit an article about the advantages of the CAS.-
 
Pitfall 5: Neglecting to Use Modifiers for Noncovered Claims

Some payers, such as Noridian Medicare, will not reimburse claims for computer-assisted navigation with arthroplasty surgeries under any circumstances. But with these payers, you should still report the appropriate T code with modifier GZ (Item or service expected to be denied as not reasonable and necessary) appended.

-Even if I know an insurance company is not paying for the 0056T at this time, I still bill it and appeal it after the first denial,- Burnett says. -I have had success in changing the policy of one company for another procedure by doing this. My hope is that if I keep appealing the CAS every time, the insurance companies will make policy changes and finally accept it.-