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Orthopedic Coding Alert

CCI 8.3:

Coding Three Knee Joint Compartments Is No Longer a Snap

Published on Fri Nov 01, 2002

The new edition of the Correct Coding Initiative (CCI), which took effect on Oct. 1, prohibits practices from appending modifier -59 (Distinct procedural service) to 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chondroplasty]) when performed with meniscectomies (29880-29881).

With CCI version 8.3, Medicare no longer recognizes three knee compartments. The edit now contains a "0" identifier, indicating that you cannot report the two services together on the same date for the same patient under any circumstances.

Until now, you could use modifier -59 to designate the difference between the two services. Despite previous CCI edits bundling chondroplasty into meniscectomies, Medicare reasoned that certain circumstances such as a medial meniscectomy with patellar chondroplasty warranted using modifier -59 to allow payment for both. CCI's new take, however, comes as a surprise to most orthopedic practices because they stand to lose significant reimbursement.

Fight the Edit

"This change will create a significant negative economic impact on surgeons. Obviously, they aren't going to alter their clinical practice and subject their patients to a second operative procedure, so they'll have to take a hit financially," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J. Stout advises practices to fight the denials vehemently.

"I would urge coders and orthopedists not to take this lying down, as doing so will set the table for future financially motivated CMS actions of this nature," Stout says. "Practices should continue to submit claims according to the American Academy of Orthopaedic Surgeons (AAOS) guidelines and appeal each and every inappropriate denial. When the appeals department and fair-hearing officers have piles of review letters on their desks, maybe the message will get through that surgeons will not simply accept inappropriate edits."

According to the AAOS Complete Global Service Data for Orthopaedic Surgery, the global service package for 29881 includes the following procedures:

  • Articular shaving, debridement, and/or chondroplasty in the same compartment, e.g., 29877, 29879
  • Plica and/or synovial resection, e.g., 29875
  • Debridement and/or shaving of meniscus
  • Debridement and/or shaving of cruciate stump
  • Knee arthroscopy, diagnostic, e.g., 29870
  • Additional portal(s) or enlarging portal(s)
  • Meniscal tissue removal
  • Knee lavage and/or drainage, e.g., 29871.

    Note that the AAOS guidelines do not include chondroplasties that occur in other compartments with the fee for meniscectomies.

    Injections Bundled Into One Another

    CCI 8.3 also bundles most injection codes into other, more extensive procedures with which they are normally performed. For instance, the new edits bundle trigger point injection codes (20552-20553) into many of the nerve block codes (64400-64530).

    Although these edits are new to CCI, many carriers have been bundling injections into other procedures for years, and version 8.3 merely makes the trend official. This does not necessarily mean, however, that your practice must write off the cost of every injection it performs with other procedures, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.

    "Medicare's thinking is that the injection should be included with any other service performed that day, but this does not preclude a practice from appending a modifier to separate the two services if both are medically necessary," Jandroep says. In particular, she points to modifiers -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when orthopedists perform injections with E/M services, and -59 when they do injections with other procedures.

    For instance, an established patient presents for a prescheduled injection but also reports an unrelated problem, such as ankle bursitis, 726.79. In this case, the orthopedist may perform the scheduled trigger point injection for neck pain (723.1), a separate E/M service (e.g., 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) for the bursitis, and a bursa injection to the ankle (20605).

    The claim would read as follows:

  • 20552 (723.1)
  • 20605-59 (726.79)
  • 99213-25 (726.79).

    Practices should record the injection documentation separately from the E/M documentation with a complete procedure note for both services.

    Other notable CCI changes include the bundling of many strapping codes (29520-29580) into most of the injection codes. Again, you can use modifiers -59 and -25 to separate the two services if both are medically necessary.

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