Orthopedic Coding Alert

Will a notchplasty with ACL reconstruction bring you extra money?

If you don't know your patella from your Hoffa fat pad, your claims are in jeopardy.
 
Check out the following questions, submitted by a subscriber in Norwood, Mass., to see whether your terminology skills can lead you to the correct CPT code.

Question 1: Is the infrapatellar fat pad (Hoffa fat pad) located in the patellofemoral, medial or lateral knee compartment, or can we consider it a patella compartment and separately bill for services in this area during a synovectomy?

Question 2: How would we separately bill for a notchplasty in the patellofemoral compartment to the anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) when the surgeon performs it in addition to a lateral meniscectomy?
 
Question 3: Is the trochlea considered part of the patellofemoral compartment, or would an insurer consider trochlea services "separate compartment" procedures?

And the Answers Are ...

Answer 1: "The patellar fat pad lies inferior to the patella behind the patellar tendon," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J. "Shaving of the fat pad is performed therapeutically for fat pad impingement or hypertrophy, and in those instances would represent a reportable service." She recommends reporting 29999 (Unlisted procedure, arthroscopy) for this service.
 
But fat pad shaving is not reportable if the physician performs it merely to facilitate visualization of the intercondylar notch, Stout says.
 
Important: Coders may also overuse the fat pad debridement code, says Mary J. Brown, CPC, CMA, orthopedic coding specialist at OrthoWest PC, a seven-physician practice in Omaha, Neb., "So you should only bill for it if you have perfect documentation. This is not something you should report on a routine basis."

Answer 2: "A patient's ACL and PCL pass through a recess between the femoral condyles that looks like an upside-down 'U,' " Brown says.  "This 'U' shape is
the notch." 
 
Some ACL tear patients have a condition called notch stenosis in which the notch is too small for the ACL and PCL to pass through. In these cases, Brown says, the surgeon performs "notchplasty" to enlarge the area and allow the ligaments to fit properly.
 
Remember: "You would not separately report a notchplasty when performing an ACL or PCL reconstruction," Brown says.
 
You should report 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) for ACL reconstructions, and 29889 (Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction) for PCL reconstructions.
 
Answer 3: The trochlea is considered part of the patellofemoral compartment, Stout says. "The trochlea is the depression on the anterior distal femur where the patella articulates with the femur," she says. "Think of it like a trough that the patella rests in."
 
Therefore, any services that the orthopedic surgeon performs in the trochlea would not be considered separate procedures from those that the surgeon performs in the patellar compartment.