Orthopedic Coding Alert

In most cases when an orthopedic surgeon assists in the treatment of a cancer patient, the oncologist is the primary physician. Orthopedic billers will avoid charges of fraud by coding for the orthopedic intervention and not for the evaluation and management (E/M) because the E/M will be billed by the oncologist.

Metastatic tumors of the skeleton are about 25 times more common than primary tumors. Treatments of the primary tumor, particularly radiation therapy, as well as growth of the primary tumor are implicated in the high incidence of metastatic tumors of the skeleton.

Scenario: A 38-year-old woman who was treated for a primary and malignant breast cancer three years earlier presents with carcinoma metastatic to the bone (198.5), secondary cancer of the femur, metastasized from the breast (174.9). X-ray examination shows a 55 percent loss of the shaft diameter of the femur (any view). Biopsy ascertains the lesion in the shaft is a carcinoma (i.e., not a sarcoma).

An orthopedic surgeon (OS) joins the treatment team, which is led by an oncologist, the womans primary physician, and a radiologist who is administering radiation therapy as a palliative treatment for pain.

The OS determines that the risk of pathologic fracture of the femur (733.14) is high, and intervenes with a prophylactic fixation of the femur.

Coding solution: CPT 27187 (prophylactic treatment [nailing pinning, plating or wiring] with or without methylmethacrylate, femoral neck and proximal femur) describes the fixation. The diagnosis corresponds to the primary site cancer and its location. For example, if it were a malignant neoplasm of the female breast in the upper-outer quadrant, the ICD would be 174.4 (malignant neoplasm of female breast; upper-outer quadrant).

In this case, because of the underlying condition, the services of the oncologist will continue throughout the global surgery period that applies to the orthopedic surgeon. The oncologist will report the appropriate E/M code, and no modifiers are needed.

Are More Coding Options Needed?

Payers view prophylactic treatment as legitimate. Currently, the extent of the involvement of the OS determines how much reimbursement the OS will receive. For example, payers do not question the bill if the intervention is limited to the prophylactic fixation or fixation of a pathological fracture.

Sheri Benton, CPC, a coding and reimbursement specialist in the department of orthopedics at the Cleveland Clinic Foundation, says, An oncologist will usually ask for an ortho intervention when cancer patients develop pathological fractures [during] chemotherapy treatments. Prophylactic treatment is common and appropriate in these instances. The cancer diagnosis should suffice for medical necessity. I have had no reimbursement problems with these.

The orthopedic surgeon should play a comprehensive role in the prevention, detection, treatment and continuing care for patients who have or are at risk for pathologic fractures, says Henry DeGroot III, MD, chief of the Musculoskeletal Oncology Service at the University of Massachusetts Memorial Medical Center in Worcester, and principal author of the bonetumor.org Web site. This should include prompt evaluation of patients referred for these problems, a systematic evaluation of fracture risk or fracture status and a patient-centered treatment plan.

The orthopedist is uniquely qualified to know whether non-operative or operative care would serve the particular patients care best. The orthopedic surgeons goal should be the maintenance of skeletal integrity using medicines, such as Fosamax and similar ones, using radiation or chemotherapy administered by others or using surgical fixation to prevent or treat pathological fractures.

As an example, a patient with breast cancer who has a new femoral metastasis would benefit from an orthopedist who assesses the known lesion, treats that lesion surgically or follows it closely if the fracture risk may increase with time, performs an orthopedically relevant search for other lesions that may be clinically significant, puts treatments in place to minimize or prevent the progression of the diseaseor the next fractureand follows up to make sure the treatment is happening and is effective.

The Reality of Payment

Reimbursement for the integral care role DeGroot recommends is another matter. Most of these interventions are not reimbursable, since we have no codes for these services, he says. Only procedures to fix or prevent fractures are payable, and these are paid willingly by my payers.

He adds a clarification. In a few tumorsprimary soft-tissue sarcomasthe orthopedic oncologist renders all the tumor care, but not primary non-cancer-related care. These services are also not billable.

The American Academy of Orthopedic Surgeons (AAOS) is working to address the concern. Blair C. Filler, MD, FACS, AAOS representative to the American Medical Association CPT Advisory Committee and consulting editor for this publication, says, The main problem is the musculoskeletal coding system is not adequate to cover all the newer methods of limb salvage. The AAOS Committee on CPT is developing a better method of reporting tumor exposure and removal, reconstruction and closure.