Orthopedic Coding Alert

"Outpatient practices will probably report 64447 more frequently than the other new codes," Hammer suggests. As a single nerve block code, orthopedists might offer it to patients who require pain management to help tolerate physical therapy following procedures such as ACL repair. "In the outpatient setting, I could foresee 64447 being used as a diagnostic tool to evaluate possible femoral nerve injuries," Hammer says.

The continuous infusion codes (64416, 64446 and 64448) will have more applications in postoperative pain management. Prior to 2002, orthopedists probably reported these procedures using 64450* (Injection, anesthetic agent; other peripheral nerve or branch) and 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). Some practices may have submitted a code in the 99231-99233 range (Subsequent hospital care ...) for the follow-up management of the infusion catheter. 

"The second code is no longer necessary, since the new code descriptions clearly state 'including daily management for anesthetic agent administration,' " Hammer says. "The new codes carry a 10-day global period, and the instructions specifically indicate that 01996 should not be reported."

The AMA's CPT Changes 2003: An Insider's View suggests you might use 64416 for postoperative pain relief and vasodilation following traumatic amputation and surgical reimplantation of a patient's thumb and forefinger. "The surgeon often requests continuous catheter pain management not only to control pain but to allow for earlier postoperative therapy to the affected sites," Hammer says. 

Likewise, you might report 64446 for postoperative pain control following major foot and ankle reconstruction due to a crush injury. CPT Changes 2003 suggests that the sciatic block might also allow earlier ambulation. 

"The clinical example offered at the AMA CPT 2003 conference for 64448 referred to postoperative pain control and increased knee mobility following a total knee replacement (27447)," Hammer says.

CPT 2003 modifies several injection code descriptors to pinpoint more specifically the area that the orthopedist injects. Foremost, the descriptor for 20550* eliminates the reference to the ganglion cyst, now reading, "Injection(s); tendon sheath, ligament."

Similarly, descriptors for 20600* (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]) and 20605* (... intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) also drop all mention of ganglion cysts. To compensate for this, CPT creates a new code, 20612 (Aspiration and/or injection of ganglion cyst[s] any location).

A note following 20612 indicates that you should report multiple ganglion cyst aspirations and/or injections with 20612-59 (Distinct procedural service).

CPT 2003 offers new descriptors for 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles), which now specify "muscles" rather than "muscle group(s)," as in 2002.

Orthopedists hoping that the revision will allow them to bill additional units of 20552 and 20553 for each muscle injected, however, will be disappointed because you should report these codes only one time per session, regardless of the number of injections or muscles injected. 

"The word 'group(s)' was removed from 20552 and 20553 because there was a great deal of confusion regarding what constituted a muscle group, and different payers were interpreting it differently," says Allison Waxler, practice management policy analyst at the American Academy of Physical Medicine and Rehabilitation, one of the groups that worked with the CPT advisory committee to effect the change.

"The codes are written to only allow each code to be billed once per day," Waxler says. "One or more injections in one or two muscles should be coded with one unit of 20552. One or more injections in three or more muscles should be coded with one unit of 20553. Providers cannot bill multiple units of either code if multiple injections are given or if multiple muscles are injected."

For instance, if the orthopedist administers three injections into the trapezius muscle, report one unit of 20552. If the orthopedist performs three trigger point injections into the trapezius muscle, two injections into the supraspinal muscle, and two injections into the paraspinal muscle, report one unit of 20553.

Note: Consultant Marvel Hammer can be reached by e-mail at marvelh@aol.com.