Orthopedic Coding Alert

CMS prices 2 new codes as over $1000 -- Will you recoup that pay?

You can stop feeling overwhelmed by the hodgepodge of new orthopedic-specific codes that will affect your practice in 2009 by simplifying the multitude of changes into five subjects:

- multiplane external fixation

- arthroplasty

- pelvic fasciotomy

- plantar common digital nerve injection

- intramuscular injection procedures.

First of all, you-ve got two new codes for multiplane external fixation. They are:

- 20696 -- Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (e.g.,spatial frame), including imaging; initial and subsequent alignment(s), assessment(s),

and computa-tion(s) of adjustment schedule(s)

- 20697-- ... exchange (i.e., removal and replacement) of strut, each.

Highlight: These codes include a lot of services (such as "subsequent alignments" and "removal and replacement"). For that reason, CMS prices these codes with high relative value units (RVU). Code 20696 has 28.14, and 20697 has 33.09. If

you multiply that by 36.0666, the 2009 conversion factor, you-ll equal more than $1000 per procedure.

If you use Category III codes when your orthopedic surgeon reports cervical total disc replacements, then you will have regular CPT codes at your disposal in 2009.

Rationale: Until recently, the data lagged behind to create Category I codes for cervical total disc arthroplasty, explained Charles Mick, MD, a Northampton, MA-based Pioneer Spine and Sports physician in "Spine Surgery/Neurosurgery" at the

CPT and RBRVS 2009 Annual Symposium in Chicago.

CPT deletes codes 0090T, 0093T, and 0096T. Instead, you-ll report these three regular (Category I) cervical disc replacement codes:

- 22856 -- Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissec-tion), single interspace, cervical

- 22861 -- Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

- 22864 -- Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical.

The descriptors are almost identical to the Category III versions.

Be careful: Be cautious about 22856, which includes the term "decompression." Why: You should consider the decompression performed at the interspace where the physician is placing the artificial disc as an inclusive part of the procedure.

In other words, you should not report it separately. "Decompression codes are difficult to apply to dictated reports," warns Pat Tietz, CPC, coder for The Twin Cities Spine Center in Minneapolis. Also, remember "your physician needs to

qualify the -segment.-"

Many coders are hopeful this will change how payers view these procedures. "The transition to regular codes" at least suggests "insurance payers can pay for the total disc arthroplasty more easily," says Lori Montanez, CPC, coder at Spine

Orthopaedic & Rehabilitation Center (SORC) in Albuquerque, N.M. "Many payers said, due to the Category III code, their system automatically denied it for -procedure experimental.-"

Other experts are dubious. "I am glad CPT changed these services into regular CPT codes; it's a step in the right direction  but unfortunately this doesn't mean insurers will reimburse for them," warns Regina H. Tinney, CPC, coding

specialist at Crossroads Healthcare Management in College Station, Texas.

For instance, Blue Cross of Idaho already lists these new codes in its "Artificial Disc: Cervical Spine" Medical Policy (www.bcidaho.com/providers/medical_policies/sur/mp_701108.asp). The policy, however, continues to state, "Artificial

intervertebral discs are considered investigational for treatment of disorders of the cervical spine, including degenerative disc disease."

If your practice deals with trauma medicine, you have a new code describing fasciotomies for pelvic compartments. They are:

- 27027 -- Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (e.g., gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral

- 27057 -- Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (e.g., gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateral).

When your physician treats a condition affecting plantar common digital nerves, you-ll have two codes to use. They are:

- 64455 -- Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g.,Morton's neuroma)

- 64632 -- Destruction by neurolytic agent; plantar common digital nerve.

Example: Morton's neuroma (355.6, Lesion of plantar nerve) is a thickening of the plantar nerve between the heads of the metatarsals. The symptoms usually include pain, tingling, burning, and/or numbness. Wearing shoes with a narrow toe box

or sports can cause it.

Currently: Some CMS carriers direct you to use a peripheral nerve injection code or an unlisted procedure code when your physician performs Morton's neuroma injections.

2009: If your physician injects a steroid or anesthetic agent for pain relief, you would use 64455. (In contrast, 64632 describes nerve destruction or chemodenervation.)

Finally, CPT 2009 deletes the entire "Therapeutic, Prophylactic, and Diagnostic Injections and Infusions" section (90765-90779).

Instead, you-ll find a new section entitled, "Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration." The codes in the new

section will run from 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) through 96379 (Unlisted therapeutic, prophylactic, or diagnostic intra-venous or intra-arterial injection or

infusion).

For your practice, this means you should strike out 90772 and instead use 96372 (Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular).

Outcome: Despite the addition of these codes, most orthopedic coders expressed disappointment rather than joy when CPT 2009 was unveiled.

"I have to use unlisted codes so often," says Leslie Follebout, CPC-ORTHO, PCS, coding department supervisor with Peninsula Orthopaedic Associates. However, Follebout says, CPT 2009 won't alleviate her need for frequent unlisted

procedure coding because it failed to produce new codes for procedures such as hip scopes, arthroscopic tennis elbow repair, arthroscopic hardware removal, and other procedures. "I probably won't use the new orthopedic codes because our

practice does not perform those services," she says