Orthopedic Coding Alert

Occasionally a physician must turn to a procedure that lies outside the normthe one most physicians would useto treat a condition. The medical justification is there. Thorough documentation, detailing the medical necessity and time spent on the procedure, will avoid reimbursement problems.

Coding for manipulation of the fingers, hand and wrist under general anesthesia to relieve arthrofibrosis proved just such a problem for one Orthopedic Coding Alert reader. The third-party payer did not respond favorably to the coder's solution.

The coder used 25999 (unlisted procedure, forearm or wrist) and 26989 (unlisted procedure, hands or fingers). The arthrofibrosis (718.5) in the patient's left wrist, hand and fingers restricted motion to about 20 percent. (Other problems with the extremities antedated the arthrofibrosis, including one that necessitated a carpectomy, and probably contributed to it.)

The commercial payer could not understand why the patient was given general anesthesia for the manipulation. And the payer compensated the practice accordinglyfor the manipulation only. The practice received reimbursement of just over $15.

Time Spent, Medical Necessity Must Be Spelled Out

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., is not surprised by low reimbursement. She says, Medicare reimburses for the amount of time spent at $17 for every 15 minutes [of manipulation]. And it sets the standard.

It's going to take a good explanation of the amount of time spent and why to get more reimbursement. You can't expect to be paid as though you are doing surgery. You might expect $40 to $45 tops for a 15-minute increment.

But Callaway-Stradley advises the coding is made doubly difficult because there is no precise code for the procedure. She reminds that without a good existing code, a -22 modifier (unusual procedural services) alerts payers to the difficulty and the case the coder is making for reimbursement.

Anesthesia poses a big problem. Even fasciotomy done to relieve hand contractures, for example, is typically done under a local anesthetic. Good documentation is essential. Why is the anesthesia being used? asks Callaway-Stradley. If the physician can make a case that the tissue is so dense and the fingers, hand and wrist so immobile, that manipulating them without anesthesia would cause excruciating pain, the procedure might be acceptable.

Two Options

Callaway-Stradley recommends going to the physical therapy code 97140 (manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes).

A -22 modifier also would be used to explain why the anesthesia is necessary. And the documentation (detailed operative report) would include detailed notes on time spent on manipulation and degree of contracture that necessitated the decision to use general anesthesia.

Annette [...]