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 Grady, CPC, CPC-H, coding and reimbursement coordinator at the Bone and Joint Center in
Bismarck, N.D., has a bit of concern that an orthopedic practice moving beyond the skeletal and muscular surgery codes may alarm some payers. She says she would approach the issue a little differently.

The first thing I'd do would be to call the carrier and get the pre-surgery approval amount, says Grady. Of course, you can't do that with Medicare. I'd ask them [the carrier] what they recommend. I'd use a cover letter with the operative report and in it I'd give an example of a comparable procedure, and what it pays.

I'd be sure to use a procedure that is as similar as possible in time and procedure, Grady emphasizes. And if the claim needs to go to a reviewer, we ask that it go to a physician with the same specialty. It may delay the payment, but it will be well worth it.

We have a little form we use for comparable codes, says Grady. Callaway-Stradley has developed a similar form, which is reprinted on page 36 of the May 1999 Orthopedic Coding Alert. She points out that using a -22 modifier gives the physician the opportunity to ask for a payment more realistic than might be available using just an unlisted code without supporting documentation, payment as much as 20 to 30 percent more.

In the end, then, Grady would probably stay with the unlisted codes, unless the payer recommended otherwise. Documentation and repeated submissions under unlisted codes are what eventually prompt the addition of codes for recurring unlisted procedures.

The use of general anesthesia for the manipulation described is not common. Callaway-Stradley and Grady give reasonable, but different approaches to the same problem. Both coders say documentation is a crucial element, and they stress the fact that codes evolve.