Orthopedic Coding Alert

In the last several years, a number of expensive new treatments for injury or degeneration of the cartilage of the knee have appeared. One of the more affordable treatments is the autogenous osteochondral transplant (also known as an OATS or MosaicPlasty). We have been performing this procedure for about a year-and-a-half, says Shari Benton, coding and reimbursement specialist with the Cleveland Clinic Foundation, Cleveland, OH. According to Benton, the procedure continues to grow in popularity primarily because it is less expensive, can be done in one procedure and can be done arthroscopically.

Understanding Knee Cartilage Repair

According to the National Center for Health Statistics, almost 5 million people visit orthopedic surgeons offices each year because of knee problems. More than 3 million of these visits are injury-related; the remaining are due to arthritis and other disorders. Another 1.4 million people go to a hospital emergency room for knee problems. Many of these problems will be related to injury or degeneration of the knees cartilage, and it is important that the orthopedic coder understand the varieties of new treatments being used.

The knee is an active joint with a large area of articulating contact. This area of contact is protected by a smooth cartilage surface that can be disrupted or lost due to injury or degeneration, causing pain and sometimes loss of movement. Historically, orthopedic surgeons have treated the problem by shaving or scraping the cartilage until it bleeds (29877). This procedure can stimulate the growth of a thick layer of scar tissue and restores a smooth articulating surface. The procedure isnt always successful, so in recent years new methods have been developed that actually transplant good cartilage into the problem area.

One of these procedures involves taking cartilage tissue from the patients knee and then sending it to a lab where it is grown under special conditions for a couple of weeks and then returned to the patients knee. However, the procedure has been impractical for many because it is often not covered by private carriers, involves two surgeries and could cost as much as $60,000.

The autogenous osteochondral transplant (which has been compared to hair transplantation) is more affordable and involves a single surgical procedure. One or several cylindrical osteocartilaginous grafts are taken from peripheral and non-weight-bearing areas of the knee (donor site) and are transferred to the prepared damaged area (recipient site) usually under arthroscopic visualization, which requires extensive arthroscopic experience and skills by the performing surgeon. There are several different techniques used to perform the procedure with each using precise instrumentation that bears the different manufacturers name and can lead to coder confusion about what was performed. Most commonly done osteocartilaginous transfers utilize one of the following instrumentation brands: OATS (Arthrex), COR Systems (Innovasive Devices), and MosaicPlasty (Smith Nephew Endoscopy). According to Benton, the coder should understand that numerous plugs or grafts could be done in a session. Numerous plugs means more work and that may affect what you bill.

Using the Right Code

Like many new procedures in orthopedics, this procedure does not have a specific code. Therefore, according to Benton, you will need to use 29909 (unlisted procedure, arthroscopy), or if the procedure is done via open surgery use the 27599 (unlisted surgical procedure, femur or knee). Benton also suggests that you have two charges (even though you will use the same codes), one for three or fewer plugs and another for four or more plugs. Four or more plugs represent substantial additional work. She goes on to say, were getting paid for these procedures, but we have to send in the operative report with the claim. Some of the private commercial carriers are denying our first claim, saying the procedure is experimental. So we appeal with an explanatory letter and dont usually have any problem with reimbursement.

Camille Norris, CPC, of Pamlico Orthopedics in Washington, NC, says they have begun to perform the osteochondral transfers. Norris uses both codes 29885 (arthroscopy of the knee, drilling for osteochondritis dissecans with bone grafting, with or without internal fixation including debridement of base of lesion) and the 29909 unlisted code described as osteochondral transfer. Weve had to send along our operative reports, but so far were getting reimbursed, she says. Benton cautions about using the 29885 code for a diagnosis other than osteochondritis dissecans (conditions where a fragment of cartilage and its underlying bone become detached from the articular surface). The diagnosis could range from osteochondritis dissecans (732.7), osteoarthritis (715.X6) to an injury. Norris notes that the procedure may also be done with a meniscus repair (29882) and the coder should be sure to include all the procedures.

Finally, Benton suggests that coders should also consider petitioning the AMA to put a specific code for osteochondral transfers in the CPT. If enough people petition the AMA about a procedure, they will consider including it in the CPT, she says. Forms for petitioning the AMA CPT committee can be obtained through the specialty society (American Academy of Orthopaedic Surgeons), from the insurance carrier (such as the BCBS Association), or the AMA Health Care Professionals Advisory Committee (HCPAC).