Orthopedic Coding Alert

Receive proper reimbursement for unlisted procedures by providing solid documentation and by going through the process of appealing denials.

As frustrating as the process of coding and getting reimbursed for endoscopic thermal capsulorrhaphy is, the endeavor illustrates why an appeal must often be considered just another part of the coding process.

Surgical techniques and technology outpace the establishment of unique CPT codes. That means an array of problems for a coder. Unlisted codes have no assigned value. Getting a payer to value the procedure the same way a practice doeseven with a thorough operative report and a KISS letteris not easy. (KISS is the acronym for Keep It Short and Simple. In this case, a KISS letter explains as succinctly as possible the procedure performed and points to the most similar listed procedure as a guide to payment. The letter aims to justify the fee requested for the unlisted procedure. An example of a KISS letter can be seen on page 36 of the May 1999 Orthopedic Coding Alert.) Worse, some procedures are considered experimental and unproven and payers will not reimburse at all, at least not in response to the first-level submission of a claim.

Endoscopic thermal capsulorrhaphy (See box) to enhance shoulder stability is one example of a procedure without a code. And it is frustrating many coders. Some coders are so frazzled they have considered using listed codes, such as the code for open capsulorrhaphy, 23455 (capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation; with labral repair, e.g., Bankart procedure) to report the arthroscopic procedure.

Hearing that idea, Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., says emphatically, Dont do it! It is not just improper coding. It is also potential fraud.

What is the solution? Perseverance and patience are what it takes to see the way through to a reimbursement.

Appeals Work

In August 1999, Ruthe Travis, administrative assistant in the department of orthopaedics at the University of Colorado Health Center, wrote to us about problems with payment for endoscopic thermal capsulorrhaphy. We recently checked in with her, and she says, We are appealing denials. And we are getting paid on appeal.

It takes persistence, but the appeals work, says Travis.

Scenario: A 20-year-old female, a college basketball player, with secondary impingement of rotator cuff tendinitis due to laxity in the shoulder undergoes a rotator cuff rehabilitation program. But the instability continues, causing the young woman problems with overhead throws, and surgery follows.

During an operating room (OR) session, [...]