Orthopedic Coding Alert

The process may be complex, but your associations can help you make it happen

Every year, you scan the list of new CPT and Category III codes to discover that the code you were anxiously awaiting did not appear. Maybe you were expecting a code for core decompression of the hip, or perhaps one to describe arthroscopic thermal shrinkage of the ACL. But another year's CPT codes were recently announced, and yours did not make the cut.
 
But you shouldn't simply assume that your most-wanted codes are destined never to be official. Instead, get to know the CPT editorial process and start writing letters campaigning for your code, and you just might see your code in CPT someday.

Make Your Case

If you would like the CPT committee to consider a new code for a procedure that you perform, you should start by contacting your professional organization. Either talk to someone at your local orthopedic association or contact a national organization, such as the American Academy of Orthopaedic Surgeons (AAOS).

-Your national organization will designate a key person on the coding and reimbursement advisory panel,- says Douglas Jorgensen, DO, CPC, a practicing physician in Manchester, Maine, and president of Jorgensen Consulting LLC. -You should write the advisory panel member a letter telling them that a particular code in CPT does not properly describe the procedure you-re performing, and explain why you-re requesting a new code or a modification of an existing code to better represent what you-re doing.-

Do Your Homework Before You Submit the Letter

Remember: You should present the association with enough research and data to justify the code that you-re recommending.

For example, you may want to submit a previously published clinical vignette of the code that you-re now using for the procedure, along with a sample operative report for the same procedure.

Ask the surgeon to write a letter explaining the differences between the vignette (which is what the code describes) and his operative report (which shows what he actually performed during the procedure).

-A few years ago, CPT stated that you should no longer just use the 52 modifier (Reduced services) to downgrade an existing code that doesn't quite describe the procedure you performed,- Jorgensen says.
 
Instead, if you don't perform the procedure that the code describes, you should use the applicable unlisted- procedure code. -But many times, particularly in surgical settings, the unlisted-procedure code doesn't accurately depict reimbursement for the service you performed,- Jorgensen says.

Editorial Panel May Not See Redundant Requests

If your association agrees that your code request is valid, your information will then make its way to the AMA, where staff members will determine whether other practices or associations have already requested codes for the same procedure.

If the AMA determines that you-ve submitted a request that they have already addressed, they will send a letter to you (or to your association on your behalf) letting you know, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

If the AMA decides to pursue your request, they-ll pass the information on to the CPT Editorial Panel, which will consider whether to create a new code for the procedure you-ve described.

Don't Discount the Power of One

Bust this myth: Some coders and physicians think that the Editorial Panel will only consider a request for a new code if hundreds of other practices have made the same request, but that isn't necessarily true, Jorgensen says. -As long as you present a cogent argument, your request should go through the process.-

The CPT Editorial Panel reviews potential changes during quarterly meetings, and CPT introduces its new codes in autumn of each year.

Note: If you-d like more information on how to request a new CPT code, visit the AMA's Web site at www.ama-assn.org/ama/pub/category/3866.html.