Orthopedic Coding Alert

CMS doesn't agree with this revision, so here's what you will have to report instead.

If you struggle for reimbursement when your physician repairs both sides of a pelvis, CPT 2009 brings welcome relief -- at least, when you submit claims to private payers.

To keep denials from hitting your desk, you must delineate what pelvic fracture repair codes to use for private payers and Medicare carriers.

CPT 2009 revises the descriptors to pelvic fracture treatment codes (27215-27218) to specify these procedures are "unilateral." This means you can append modifier 50 (Bilateral procedure) in cases when your physician is repairing both sides of

the pelvis and expect 150-percent reimbursement. Here are the new definitions (emphasis added):

- 27215 -- Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed

- 27216 -- Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum)

- 27217 -- Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral

superior/inferior rami)

- 27218 -- Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum).

Translation: Suppose your orthopedist performs the work represented by 27218 on both sides of a patient's pelvis. This means you can apply modifier 50 to 27218. Calculate: Currently, the work relative value units (RVUs) for 27218 are 20.93. In

2008, Medicare automatically applies a budget neutrality adjustor (BNA) to the work RVUs of a procedure, which in this case will lower the work RVUs for 27218 to 18.43 (20.93 x 0.8806 BNA = 18.43, rounded to two decimal places). Adding the

adjusted work RVUs to the physician expense (PE) RVUs and the malpractice RVUs for 27218 yields a total of 33.29 RVUs (18.43 work RVUs + 11.37 PE RVUs + 3.49 malpractice RVUs = 33.29 total RVUs). Multiply the total RVUs by the 2008

conversion factor (38.087) to arrive at the fee: $1267.92 (unadjusted for geography).

In 2009, CMS will apply the BNA to the conversion factor, not just to the work RVUs. Take the total 2009 RVUs for 27218 (20.93 work RVUs + 11.68 PE RVUs + 3.49 malpractice RVUs = 36.10 total RVUs) and multiply them by the 2009

conversion factor, 36.0666, to calculate your reimbursement: $1302.00. This is a $34 increase from the 2008 reimbursement ($1302.00 - $1267.92 = $34.08).

You can calculate your bilateral reimbursement for 27218 by multiplying the fee by 1.5. In 2009, bilateral reimbursement for 27218-50 should reach $1953.00 ($1302.00 x 1.5 = $1953.00), which is $651.00 more than the unilateral reimbursement in

2009 ($1953.00 - $1302.00 = $651.00).

Benefit: Bilateral reimbursement for 27218 in 2009 should be about $685 more than the unilateral reimbursement for 27218 in 2008 ($1953.00 - $1267.92 = $685.08).

"This is a welcome change -- so long as carriers reimburse for both procedures and follow CPT guidelines," says Connie Treonz, practice administrator for Associated Orthopaedics in Union, N.J.

Catch: In 2009, you will need to monitor your private payers to learn whether they will deny your claims, despite this new verbiage. "Unfortunately, carriers sometimes have their -own- encrypted claim rules overriding CPT guidelines and Correct

Coding Initiative (CCI) edits," Treonz says.

Action: "I think offices should call insurers they deal with and see how they would like you to bill these codes," Treonz advises. "I would suggest speaking to a supervisor, since representatives will result in different interpretations."

One thing's certain -- Medicare won't change its stance. CMS believes pelvic fracture care codes are not unilateral, despite CPT's revisions. Therefore, you have new G-codes that include the terms "unilateral and bilateral." In the 2009 physician

fee schedule, you-ll find this explanation:

"We do not agree with CPT and the AMA (Relative Value Update Committee) that the pelvis is a unilateral structure and that the code descriptor change was editorial. The pelvis is formed by adjoining the ilium, ischium, pubis, and sacrum

together. Clinically, it is a single anatomic entity and has been referenced as a single anatomic entity. We believe the previous code descriptors more accurately describe the structure of the pelvis and subsequent treatment of fractures."

"CMS-1403-FC states they have already put indicator -I- on the newly revised codes (27215-27218), meaning you will face an automatic denial if you use them instead of these new G codes," says Jacqui Jones, office manager for an orthopedic

physician practice in Klamath Falls, Ore.

Here are the four new G codes you-ll use for Medicare patients:

- G0412 -- Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral or bilateral for pelvic bone fracture patterns which do not disrupt the pelvic ring, includes internal fixation, when performed

- G0413 -- Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral or bilateral (includes ilium, sacroiliac joint and/or sacrum)

- G0414 -- Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation when performed (includes pubic symphysis and/or superior/inferior rami).

- G0415 -- Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation, when performed (includes ilium, sacroiliac joint and/or sacrum).

These definitions are almost exactly the 2008 definitions for 27215-27218. For Medicare patients, "this shouldn't present a big problem. Just another thing to remember and add to the confusion," Treonz laments.

Tip: "We keep track of CMS's replacement HCPCS codes by writing next to the corresponding CPT code in the CPT book," Jones says.