Orthopedic Coding Alert

If your insurer follows AAOS guidelines, you may not be able to report separate-compartment plica resection

If your orthopedic surgeon performs a lateral meniscectomy and a medial plica resection, don't write off the more than $500 that Medicare allots for 29875. You can bill for both procedures as long as you append modifier -59 to the plica resection code and your carrier follows CPT or Medicare guidelines.

The National Correct Coding Initiative (NCCI) created a firestorm last year when it stopped allowing coders to report 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chondroplasty]) along with separate-compartment meniscectomies (29880-29881). But if you worried that the same fate would befall plica resection with meniscectomy, don't fear: The edit bundling 29875 (... synovectomy, limited [e.g., plica or shelf resection] [separate procedure]) into the meniscectomy codes still carries a "1" indicator. This means that you can continue to use modifier -59 (Distinct procedural service) to separate the edit if you perform the procedures in separate knee compartments.

Document Separate Compartments

Many insurers follow NCCI's lead, allowing you to report 29875-59 with your meniscectomy claims, and CPT also advocates this method.

Fact: "According to AMA/CPT guidelines, it is appropriate to report plica resection in addition to meniscectomy (29881, Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]) when different compartments are involved," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J. "This appeared in the August 2001 issue of CPT Assistant. The problem, of course, is getting insurance carriers to pay for both procedures."

Solution: If your insurer's guidelines follow CPT's lead on plica resection but the payer denies your claim for separate-compartment plica resection anyway, you should appeal, says Cindi Thomas, RMA, appeals specialist at McBride Clinic, a 24-physician practice in Oklahoma City. "We bill both procedures if the operative report indicates that the physician addresses a significant plica that is impinging on the joint.

"If the insurer denies the resection, we send an appeal letter with copies of the operative report," Thomas says. "We also send a letter explaining that we didn't simply perform an incidental synovectomy for visualization of the joint, and that the patient would have continued to have problems if it had not been removed. Good documentation in the operative report is key. We have good luck appealing this scenario."

Insurer Follows AAOS Guidelines? Don't Bill 29875

Although many payers follow the NCCI and CPT's lead, some insurers may follow the American Academy of Orthopaedic Surgeons' (AAOS) guidelines, which do not advocate reporting both the plica resection and the meniscectomy together.

"The AMA and the AAOS appear to part company on this issue," Stout says. "The AAOS Global Service Data publication lists plica resection as being included in the global service package of 29881."

Watch out: If your carrier follows AAOS guidelines, therefore, you cannot report 29881 with 29875-59, even
if you perform a lateral meniscectomy and a medial
plica resection.

Don't Forget Synovectomy Code

If your surgeon performs synovectomy in a different compartment than the meniscectomy and plica resection, you can also report 29874-59 (Arthroscopy, knee, surgical; for removal of loose body or foreign body [e.g., osteochondritis dissecans fragmentation, chondral fragmentation]) as well.

In black and white: According to the August 2001 CPT Assistant, "If a knee arthroscopy for removal of loose or foreign bodies (29874) is performed in a different knee compartment as the knee arthroscopy procedure codes 29875-29881, then code 29874 may be reported separately with modifier -59 appended."