Orthopedic Coding Alert

"Orthopedic surgeons often perform anterior cruciate ligament (ACL) repair and chondroplasty (to close a lesion or microfracture) during the same operating room session. Although a unique CPT code exists for each procedure, not all payers recognize the two as separate events when they are performed in tandem.

The Scenario: A woman with a 10-year-old ACL reconstruction twisted her knee when she lifted a heavy package and lost her balance. For the first time in ten years, the woman began to experience pain and instability in her knee, which continued despite conservative treatment of rest, anti-inflammatory medication and rehabilitation. The woman opted for an ACL revision.

Arthroscopic evaluation of the ACL confirmed its incompetence, and the ACL was reconstructed anew using a portion of the patients patellar tendon (autograft). During the same operating session, arthroscopic evaluation revealed damage to the articular cartilage, specifically grade II to III changes on the medial femoral condyle. An inferomedial portal was established and a chondroplasty was performed.

Codes 29888 and 29877

Coding the ACL revision: CPT code 29888 (arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) applies even though the patient is undergoing a revision. But because it is a revision, it is important that the diagnostic code show the current, work-related injury, according to Peggy A. Hapner, CCS, RRA, a consulting services manager at Medical Learning Inc. in St. Paul, MN.

Coding the chondroplasty: CPT code 29877 (arthroscopy, knee, surgical; debridement shaving of articular cartilage [chondroplasty]) applies to the chondroplasty (a procedure that aims to stimulate growth of new cartilage across a lesion or microfracture), if the payer recognizes the procedure as separate from the ACL revision. If the procedure is done by itself, this is the correct code.

Note: A chondroplasty performed with procedures other than ACL repair may be bundled with those procedures. See the January 1999 issue of Orthopedic Coding Alert for a review of this topic.

Not All Payers Recognize Separate Codes

Its easy to get complacent when unique codes are available for procedures performed in separate pockets during the same surgical session. But what appears like straightforward coding can be more complex.

The Correct Coding Initiative (CCI), also known as the National Correct Coding Policy, which was developed at the request of the Health Care Financing Administration (HCFA), precipitates the difficulty with 29877. The CCI considers arthroscopic ACL and chondroplasty procedures performed at the same time to be bundled under CPT code 29888, explains Hapner.

The CCI is not in effect at hospitals yet, continues Hapner. But payers are already using 29888 to bundle the procedures.

Others echo Hapners experience. A lot of payers are not wanting to pay 29877, explains Sheri Benton, CPC, a coder at the Cleveland Clinic Foundation. They consider it unbundling.

To better the chances for payment, Benton says, I use a -59 modifier (distinct procedural service) up front.

Benton emphasizes, Sports surgeons agree with 29877. And a coder at one of the premier sports clinics in the nation says that the 29888 and 29877 are used routinely and payers react favorably.

What explains the success some claimants have with using the separate codes? The response varies by region, according to Hapner.

How Much Help Is the -59 Modifier?

It might help to draw the payers attention to the separate components, according to Susan Callaway- Stradley, CPC, CCS-P, an independent coding consultant who was named the American Association of Professional Coders Coder of the Year. And the -59 modifier serves that purpose well.

But Callaway-Stradley emphasizes, Some commercial carriers consider chondroplasty bundled [if it is performed in a surgical session with an ACL repair]. She notes that those payers are not going to change their position. And she recommends coders call any payer with whom they are not familiar to find out whether it accepts the 29877 code.

Alternatives to Chondroplasty

Instead of using the technique of scraping to encourage the growth of new cartilage, some physicians are turning to the use of cartilage plugs, an osteochondral autograft transplant (OAT) procedure. The OAT is so new it is coded as 29909 (unlisted procedure, arthroscopy).

And on the horizon is the autologous chondrocyte implantation (ACI). In the ACI, cartilage cells are removed, cultured outside the body and then, when available in more robust numbers, implanted (about three to four weeks later). A researcher in Sweden developed the technique. If ACI wins acceptance in the US, it is another candidate for 29909.

Because the 29909 code signifies an unlisted procedure, a copy of the operative report must be included with it. And, as a general reminder, Callaway-Stradley cautions that 29909 brings mixed reactions. Hapner agrees: It has become an issue recently that certain payers do not like the unlisted procedure code. Medicare, for example, says to get something more specific.

What if the 29909 must be used? Be sure, says Callaway-Stradley, to include documentation to prove the effectiveness of the procedure. Demonstrating that a relatively new technique is tried and brings expected results takes time, but ultimately it speeds up the reimbursement process."