Orthopedic Coding Alert

The American Medical Association (AMA) released CPT changes for 2001 in November 2000. Although the code changes do not take effect until Jan. 1, 2001, orthopedic coders are encouraged to prepare for them now to facilitate a smooth transition after the beginning of the year.

The new codes accomplish several things, explains Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., an 11-physician practice representing various orthopedic specialties. In a few cases, they eliminate the need to use unlisted codes, and they create specific codes for procedures that otherwise would have been lumped in with other procedures and articulated by using modifier -22 [unusual procedural services]. According to Stout, the new codes, while few, are beneficial to orthopedists.

Musculoskeletal Codes

CPT introduced a new group of codes into the spine section of the musculoskeletal category. Titled Vertebral Body, Embolization or Injection, the section contains three new codes for percutaneous vertebroplasty.

22520 percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic;

22521 percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar; and

22522 percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure).

This new section benefits orthopedic spine surgeons in two ways. Prior to the creation of these codes, surgeons had to assign 22899 (unlisted procedure, spine) to the vertebroplasty and include thorough documentation describing the procedure(s) performed. Not only do the new codes address this lack of specificity, they also designate between thoracic and lumbar procedures. As a result, if a surgeon performs a vertebroplasty to both the lumbar and thoracic regions, or to multiple additional vertebral bodies in either of those regions, he or she can use different, multiple codes to describe the procedure. For example, a vertebroplasty to the lumbar region and two thoracic vertebroplasties, all performed within the same surgical session, are coded as follows per CPT 2000:

22899 for the lumbar vertebroplasty;

22899-51 for the first thoracic vertebroplasty, with a multiple procedures modifier; and

22899-51 for the second thoracic vertebroplasty, also with the multiple procedures modifier.

Using CPT 2001 and the new codes, the session would be coded as follows:

22521 for the lumbar vertebroplasty;

22520-51 for the first thoracic vertebroplasty, multiple procedures; and

22522 for the second thoracic vertebroplasty.

Although coders can still anticipate a significant reduction in fees for the secondary procedure (usually 50 percent), these new codes ensure that fewer red flags will be raised as might be with multiple use of the unlisted code. Also note that increasingly, many payers will automatically reduce payment on any codes subsequent to the primary code regardless of whether the coder uses modifier -51. No reduction should be taken on 22522, however, due to its designation as an add-on code. Because add-on codes cannot be reported as a primary procedure (i.e., their description usually includes the term each additional), their relative value is already reduced. Therefore, no multiple surgical procedure reduction should be applied.

The other new code added to the musculoskeletal subsection, 21199 (osteotomy, mandible, segmental; with genioglossus advancement), will benefit oral or maxofacial surgeons by signaling to carriers that in addition to restructuring the jaw bone (mandible), the surgeon lengthened the chin (genioglossus) in the process. Prior to this new code, any additional chin work would have been explained in the documentation, and modifier -22 would have been added to 21198 (osteotomy, mandible, segmental) to indicate the extra work performed.

Nervous System Codes

One revision and two new codes in the spine and spinal cord series of the nervous system subsection will benefit orthopedic spine surgeons.

63040 laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical;

63043 laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; each additional cervical interspace (list separately in addition to code for primary procedure); and

63044 laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; each additional lumbar interspace (list separately in addition to code for primary procedure).

63040 was revised to allow the addition of the new codes 63043 and 63044. These revised and new codes give spine surgeons a method of reporting additional levels when performing a revision lumbar laminotomy. Previously, the base codes 63040 or 63042 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; lumbar) would have been reported with modifier -22 to indicate that additional work was done. Now, when the surgeon performs these procedures in the same surgical session, the primary procedure or base code will be reported as a stand-alone code, followed by the add-on laminotomy codes.

Note: As previously mentioned, many payers automatically reduce payment on any codes subsequent to the primary code with or without the -51 modifier.

New Modifiers

CPT 2001 offers two new modifiers, -27 (multiple outpatient hospital E/M encounters on the same date) and -60 (altered surgical field).

Note: Due to a typographical error on the inside front cover of CPT 2001, modifier -60 is not listed. It is, however, listed and defined (as are all modifiers) in Appendix A of the manual, beginning on page 357.

The addition of modifier -60 is important to orthopedic surgeons. It will be appended to the base code when the complexity or time of the procedure was substantially increased due to a significantly altered surgical field. An altered surgical field may result from the effects of prior surgery, marked scarring or adhesions, infection, or distorted anatomy. A few circumstances the orthopedic surgeon may encounter, which would warrant the use of this modifier, include:

Total hip replacement on a patient with a congenital anomaly of the acetabulum (the cup-shaped depression on the hip bone where the femur meets the hip);

Surgery on a morbidly obese patient, which significantly complicates the surgical dsissection; and

When scarred tendons and nerves must be freed up before completing an implant removal.

Carriers will set their parameters for additional payment of modifier -60, although that is unlikely to happen by Jan. 1, 2001. If appending the new modifier before your carrier has set payment rules, discuss with your physician the amount that the charge for the base code should be increased, relative to the amount of extra work required.