Orthopedic Coding Alert

CPT 2010 introduces a slew of new and revised musculoskeletal codes related to tumor excision. Watch these areas to ensure you're ready to code your orthopedist's work correctly when the time comes.

John F. Bishop, PA-C, CPC, with Bishop and Associates in Tampa, Fla. offers this front-end advice for grasping the changes:

• Determination point: The code levels are distinguished by size. Some have 3 cm as the dividing point between codes, but others are based on 5 cm.

• Depth: The codes differentiate between subfascial, subcutaneous, and radical resection levels. "'Deep' or 'subcutaneous' means the doctor is going below the fascia," Bishops says. "It's very clear by the codes and is good to finally have it in writing."

• Lesion type: You don't have to be reporting a malignant lesion to use the radical resection codes. "You can use the new 'excision of tumor' codes for malignant or benign lesions of any level," Bishop says. "But the radical resection codes don't detail the level because 'radical' implies a certain type of closure with layers that's routine."

• Numerical disorder: Pay attention to resequenced codes. "Some old codes were originally retired and have been brought back for CPT again," Bishop explains. "The old code numbers are still being used so they don't follow the normal sequence of events or codes. Watch those codes mixed in with the ones you normally use." For example, excision codes for hands and fingers include revised code 26115 (Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm) followed by resequenced (or reintroduced) code 26111 (... 1.5 cm or greater).

"The defining size is the size of the resection" or the mass that your physician removes, said Albert E. Bothe, Jr., MD, speaking at the AMA CPT and RBRVS 2010 Annual Symposium.

Example: A femur lesion measures 2 cm but requires your orthopedist to perform resection down to the subcutaneous layer of 4 cm. "You should use the larger of the subcutaneous codes," Bothe said. The size of the lesion is the lesion.

Why: If the surgeon removes only the lesion, you use the lesion size as the lesion excision (2 cm in our example). If your surgeon indicates he also had to remove a larger size of tissue, however, select the excision code based on the resection size.

Code choice: In the example above, the resection size is 4 cm, which is more than the 3-cm cut point in 27327's new descriptor (Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm). Therefore, you report 27337 (... 3 cm or greater).

Teach your physicians to watch their documentation with the new tumor excision codes because their notes will affect your code choice -- and their bottom line.

"If the surgeon documents just the size of the lesion and not the resection size, you could end up with a lower code," Bothe says.

"The best time for the surgeon to indicate the resection's size is when he's doing the removal," says John P. Heiner, MD, with the American Academy of Orthopedic Surgeons. The mass shrinks when it's put in preservation for specimen handling, so documenting the mass size based on the pathology report will give you a lower measurement.

When your surgeon removes a deep tumor and closes separate layers to complete the procedure, you also might be able to report codes for the closure. CPT guidelines state that tumor excision codes include simple and intermediate repair, but watch for details that might lead to a complex closure code (13100-+13153) instead.

Documentation of closing three or more layers equals a complex closure.

Example: According to the 2009 Medicare Physician Fee Schedule, the national average facility fee for 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) was $174.92. The comparable code for a complex closure, 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm), would garner $292.89 instead.

"Don't cheat your doctor out of pay for complex closure," Bishop says. "Train him to document thoroughly and to indicate the layers he's dealing with so you can include everything in the claim."