Orthopedic Coding Alert

Know where the arthroscopically aided procedures override the open approach.

When your surgeon combines an open approach with an arthroscopic procedure, you'll be on top of your game if you're clear on reporting cases in which just part of the procedure is open approach. Follow our advice on correctly assigning seven key arthroscopic procedure codes that apply to arthroscopically aided procedures.

Count Condyles to Select Between 29855 and 29856

Your surgeon may use arthroscope-assisted repair for the proximal tibial fracture in the tibial plateau that has a displacement and/or depression of the condylar surfaces. Specifically, tibial condylar fractures with ligamentous and meniscal injuries may require an arthroscopic-assisted elevation and screw fixation.

Rationale: An arthroscopic approach causes less tissue damage than an open approach, aids to reduce depressed articular fractures, and allows for lavage in the joint. Arthroscopic approach also helps to remove hematoma, and allows concurrent work on ligamentous and meniscal injuries," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Coding scenario: Let's say you read in the operative note that your surgeon was treating a young patient with an unstable joint and a depressed fracture of the tibial plateau. You read further to confirm how the repair was done and to confirm if he used an arthroscopic approach. You read that your surgeon visualized the fracture in an arthroscope, made a window in the metaphysis, and elevated the depressed articular surface. You can further read that your surgeon used a graft for subarticular support and then used 1-2 cannulated screws or a plate to support the fracture.

In this case, you turn to code 29855 (Arthroscopically aided treatment of tibial fracture, proximal [plateau]; unicondylar, includes internal fixation, when performed [includes arthroscopy]) if your surgeon is repairing a unicondylar fracture and to code 29856 (Arthroscopically aided treatment of tibial fracture, proximal [plateau]; bicondylar, includes internal fixation, when performed [includes arthroscopy]) for a bicondylar repair.

Tip: The codes 29855 and 29856 include the arthroscopy and the internal fixation, when performed.

Note: For bone grafts, you report code 20900 (Bone graft, any donor area; minor or small [eg, dowel or button]) or 20902 (Bone graft, any donor area; major or large) depending upon whether the graft was small or large.

Look to 29888 for Cruciate Ligament Repair, Augmentation, Reconstruction

You may read in the procedure notes that your surgeon did a diagnostic arthroscopic examination of the knee and harvested the central third of the patellar tendon. You may further read that after repairing the remaining tendon, your surgeon placed drill holes into the tibia and the femur and then pulled in the graft through the drill holes such that the graft was positioned in the same position as that of the original ACL and was held by screws.

In this case, you would report the ACL repair and opt for code 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction). The procedure your surgeon is doing is the repair of the ACL and the patellar tendon is used for the repair. Your surgeon positioned the graft and held it secure with screws.

Note: The descriptor of code 29888 specifies three options for the ACL handling, i.e. repair, augmentation, or reconstruction. You report the same code for either of these descriptions that you confirm in the procedure notes.

Pick Up the Discrete Code for Posterior Cruciate Ligament Repair

You may read in the procedure note that your surgeon did a diagnostic arthroscopy and confirmed a PCL rupture. Your surgeon will then debride the PCL remnant at the tibial insertion and prepare a tunnel for graft insertion. To prepare the graft, your surgeon used an anterior tibialis tendon allograft which is split halfway and whip-stitched and then appropriately sized and loaded on an AperFix femoral fixation device. The surgeon then passes the prepared graft through the tunnel and secures it at the femoral and the tibial ends.

For these services, you would report 29889 (Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction) since your surgeon is repairing the PCL rupture with an anterior tibialis allograft.

You Can Select 29892 Irrespective Of Internal Fixation

You're likely to encounter arthroscopy for osteochondritis dessicans, the commonest cause for a loose body in the ankle. Your surgeon may adopt an arthroscopic evaluation and repair in a patient with persistent complaints of pain and tenderness in the ankle.

In arthroscopic-aided treatment of osteochondritis dessicans, your surgeon may remove the fragment, or debride the cartilage. If this is the case, you would report code 29892 (Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation [includes arthroscopy]). As the descriptor clearly states that arthroscopy is inclusive in the code, you do not report any additional code(s) for the arthroscopy per se.

Similarly, you also report code 29892 for the arthroscopic repair of the talar dome fracture or tibial plafond fracture irrespective of whether internal fixation was done or not for these conditions.

Note: The intraoperative services which are included in the global package are the synovial resection for visualization, arthroscopic debridement of the index lesion and any manipulation under anesthesia that your surgeon does. Therefore, you cannot report 29892 and 29897 (Arthroscopy, ankle [tibiotalar and fibulotalar joints], surgical; debridement, limited) or 27860 (Manipulation of ankle under general anesthesia [includes application of traction or other fixation apparatus]) together.

Exception: However, if you read that your surgeon made a separate incision to remove a foreign body or that the foreign or loose body had a size greater than 5 mm, you turn to code 29894 (Arthroscopy, ankle [tibiotalar and fibulotalar joints], surgical; with removal of loose body or foreign body). "This however is an AAOS guideline that not all payers may recognize," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Confirm Internal Fixation Before You Report 29850 Or 29851

When you report fractures of the intercondylar spine(s) or tibial tuberosity in the knee, you'll need to confirm if internal fixation is being done before you select a code. You will however disregard any manipulation that your surgeon does. "The manipulation is inclusive to the internal fixation," says Mallon.

Anatomy refresher: There are two tibial spines, the medial and lateral tibial spines. These form the most distal aspect of the anterior cruciate ligament (ACL) complex. Tibial spine fractures are hence indicative of the disruption of the ACL complex, the integrity of which is important for the knee stability and mobility.