Orthopedic Coding Alert

If your orthopedist frequently relies on fluoroscopic guidance or sometimes reports moderate sedation for procedures, the latest Correct Coding Initiative (CCI) edits bring big changes for your coding. CCI 15.3 went into effect Oct. 1 and includes thousands of new, swapped, and terminated code pairs you need to implement -- especially since some changes could hit your bottom line.

CCI 15.3 includes 18,320 new edit pairs, according to a summary report by Frank Cohen, PA, of MIT Solutions, Inc. in Clearwater, Fla. "The overwhelming majority have a modifier indicator of 0, meaning you cannot use a modifier even if you think it is appropriate," Cohen stated in a press release.

The most frequent codes you'll see in new edits represent moderate sedation:

• 99148 -- Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

• 99149 -- ... age 5 years or older, first 30 minutes intra-service time

• +99150 -- ... each additional 15 minutes intra-service time (List separately in addition to code for primary service).

CCI 15.3 pairs almost all musculoskeletal surgery codes (20000-29999) with the moderate sedation codes.

You can easily see why reporting moderate sedation for some procedures is incorrect, because anesthesia is inherent in the descriptor (such as 22505, Manipulation of spine requiring anesthesia, any region). The bulk of remaining edits should also be easily understood because an anesthesiologist would be present during the procedure, meaning your orthopedist wouldn't need to provide moderate sedation.

"Note that the majority of the new edits were for moderate sedation performed by another physician instead of the performing surgeon," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. "It makes sense that the physician reporting the surgical codes would not be able to report these particular moderate sedation codes that require a different provider performing the moderate sedation services."

The edits classify fluoroscopic guidance as the "standard of medical/surgical practice" with many orthopedic procedures, so watch for some far-reaching fluoroscopy bundles. For example:

• Every arthroscopy code except 29999 (Unlisted procedure, arthroscopy) is bundled with 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]).

• Other orthopedic codes bundled with 76001 range from 25565 (Closed treatment of radial and ulnar shaft fractures; with manipulation) and 25800 (Arthrodesis, wrist; complete, without bone graft [included radiocarpal and/or intercarpal and/or carpometacarpal joints]) to 29065 (Application, cast; shoulder to hand [long arm]) and 29075 (... elbow to finger [short arm]).

CPT's new code 64455 (Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [e.g., Morton's neuroma) is another frequent partner with orthopedic codes in CCI 15.3. Be on the lookout for edits when your physician administers the injection along with other foot procedures.

Bright side: The good news is that the pairs involving 64455 carry a modifier indicator of 1, so you can report a modifier to unbundle the edits when appropriate. Before unbundling the edit, keep two tips in mind:

• If you're filing a Medicare claim, verify that your surgeon performed the two procedures at different anatomic sites.

• If you're dealing with another payer that follows CPT guidelines, be sure you meet all requirements for modifier 59 (Distinct procedural service) usage before reporting the modifier.

As an orthopedics coder you have about 50 "swapped edit pairs" to change in your system.

This part of CCI 15.3 includes common procedures such as 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29807 (... repair of SLAP lesion). The Column 1 and Column 2 designations for the affected pairs have flip-flopped, so pay special attention to which procedure is now comprehensive versus component.

Example: Previous CCI edits listed 29806 in Column 1 and 29807 in Column 2. CCI 15.3 reverses those places back to an effective date of July 1, 2004 (by listing 29807 in Column 1 and 29806 in Column 2).

"One important reminder is that the modifier must be appended to the Column 2 code and not the lower relative value unit (RVU) code," Hammer says. If you append the modifier to the Column 1 code instead of the Column 2, however, the carrier will deny your claim.