Orthopedic Coding Alert

Find the answers to top-5 questions

Knee arthroscopy is a surgical technique whereby the surgeon inserts a tube-like instrument into a joint to inspect, diagnose and repair tissues. Arthroscopic surgery on the knee involves inserting a small camera (less than 1/4 inch diameter) into the knee joint through a small incision (barely larger than the camera).

This camera is attached to a video monitor that the surgeon uses to see inside the knee. For a simple surgical procedure, a local or regional anesthetic is administered, which numbs the affected area, but the patient remains awake and able to respond. For more extensive surgery, general anesthesia may be used.

After the physician inserts the camera, he pumps in saline under pressure to expand the joint and to help control bleeding. Some surgeons also use a tourniquet to prevent bleeding, but this can obscure the picture on the monitor. After looking around the entire knee for problem areas, the surgeon usually makes one to four additional small incisions to insert other instruments.

Commonly used instruments include a blunt hook to pull on various tissues, a shaver to remove damaged or unwanted soft tissues, and a burr to remove bone. At the completion of the surgery, the physician drains the saline, closes the incisions, and applies a dressing. 

Background: The knee joint is the largest joint in the body. Anatomists and orthopedists usually describe it as having three compartments. A common term in an orthopedist's chart is a patient described as having -tri-compartmental osteoarthritis,- meaning that all three compartments are involved with arthritic change. The three compartments are the medial compartment, the lateral compartment and the patello-femoral compartment.

The medial and lateral compartments are described more accurately as the medial femoral-tibial compartment and the lateral femoral-tibial compartment, respectively.

The knee includes another anatomic region, termed the intra-articular notch. This is the open posterior area of the femur between the medial and lateral femoral condyles. It is often operated upon because it contains the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), but it is really not considered a -compartment- for coding purposes.

Want to know what you can bill with your arthroscopy claims? Here are five pressing knee coding questions and expert answers on how to code them.

Bypass Limited Synovectomy Bundles

Question 1: When the surgeon performs separate compartment synovectomy with meniscectomy, which code combination should we report?

Answer: You have two coding choices when your surgeon performs synovectomies: 29875 and 29876. The National Correct Coding Initiative (NCCI) bundles 29875 into meniscectomy (29881), but the major synovectomy (29876) is not bundled, and you can bill it in addition to 29881.

Here's how you tell whether the synovectomy is limited or major: Look in your operative report for the phrase -plica resection- if the physician doesn't specifically use the word -compartment- to designate the procedure's extent. This term indicates a limited synovectomy. Some surgeons also refer to limited synovectomies as -shelf resections.-

A major synovectomy includes two or more of the three knee compartment areas (or -joint locations-) and is a long and tedious procedure intended to treat extensively diseased internal joint linings as seen with rheumatoid arthritis, pigmented villonodular synovitis or hemophilia.

Therefore, if your surgeon performs a medial meniscectomy and medial and lateral synovectomies, you should report 29881 and 29876.

ACL Repair With Meniscectomy? Turn to Modifiers

Question 2: Our surgeon performed an arthroscopic-aided ACL repair with repair of the medial meniscus and partial lateral meniscectomy. Which codes should we report?

Answer: You should report three codes on three separate lines, as follows:

- 29888 for the ACL repair

- 29882 with 59 (Distinct procedural service) for the medial meniscus repair

- 29881-59 for the partial lateral meniscectomy.

Note: You may have to add modifier 51 (Multiple procedures) to 29882 for private payers. You won't have to do this for Medicare because Medicare carriers add the 51 automatically.

The surgeon cannot repair and excise the same meniscus, so because he repaired the medial meniscus and excised the lateral meniscus, you can report both codes.
The operative note should clearly indicate that the surgeon addressed both the lateral and medial menisci to ensure that the payer reimburses both procedures.

Tread Carefully With Debridement, Meniscectomy

Question 3: Our surgeon performed an arthroscopic partial medial meniscectomy and then debrided the anterior cruciate ligament stump. Can we report both 29881 and 29877 to the patient's insurer?

Answer: No. You should report only 29881 for this combination.

Although some surgeons erroneously report 29877 with 29881, the American Academy of Orthopaedic Surgeons includes ACL debridement as part of 29881. In addition, NCCI bundles 29877 into 29881.

2 Meniscectomies Equal 1 Code

Question 4: How should we report separate compartment meniscectomies? In other words, which codes can we bill if the surgeon performs meniscectomy in more than one compartment at a time?

Answer: Surgeons can and often do perform meniscectomies in more than one compartment. Code 29881 describes a meniscectomy in either the medial or lateral compartment, whereas 29880 refers to meniscectomies in both the medial and lateral compartments. Therefore, if your surgeon performs medial and lateral meniscectomies on the same knee at the same time, report one unit of 29880.

Exception: The only time you can report two units of 29881 during medial and lateral meniscectomies is in the rare case that your surgeon performs them on separate knees.

For example, if she performs a medial meniscectomy on the left knee and a lateral meniscectomy on the right knee, you should submit 29881-LT (Left side) and 29881-RT (Right side), along with a copy of your op report.

Append 22 for Revised Reconstructions

Question 5: Another orthopedic surgeon performed a faulty ACL reconstruction on a patient, and our surgeon had to go in and perform an enormously complex revision of the reconstruction to repair the problem. How should we report our revision?

Answer: Sometimes patients can walk around for years with a flawed ACL reconstruction, only to re-injure themselves playing sports or twisting their knees. Unfortunately, only one code describes these taxing and time-consuming operations: 29888.

The problem is that the ACL revision can be more complex than what 29888 describes. For example, your surgeon may have to remove the hardware that the other surgeon left in place, take out a previously placed tendon graft, and revise tibial and/or femoral tunnels. Also, scar tissue may make surgical dissection more complicated.

You should convey all of this potential extra hard work by adding modifier 22 (Unusual procedural services) to 29888. Submit supporting documentation along with the claim, explaining why you appended the modifier and how the revision differed from the initial repair/reconstruction.

Know Compartments to Select Arthroscopy Codes

The compartments are important for coding because NCCI bundles procedures that surgeons perform in the same compartment. For example, if the physician performs a medial meniscectomy and a concurrent synovectomy on the medial side of the knee, you may charge only one code because both structures are in the same compartment.

Learn Anatomic Terms to Select Code

Op report tip: If you see any of the following terms in your surgeon's operative note, you-ll know that the procedure occurred in the medial compartment:

- Medial meniscus -- anterior and posterior horns

- Medial femoral condyle

- Medial tibial plateau

- Medial ligamentous structures -- medial collateral ligament (internally).

Look for the following terms to indicate that the surgeon addressed the lateral compartment:

- Lateral meniscus -- anterior and posterior horns

- Lateral femoral condyle

- Lateral tibial plateau

- Lateral ligamentous structures -- lateral collateral ligament (internally) and the popliteus tendon.

You can rest assured that the surgeon addressed the patello-femoral compartment if he documents the following: Surgery in the deep surface of the patella or the superficial surface of the anterior femur, usually termed the -trochlear groove.-

Be on the lookout: A fibrous structure, termed a -plica,- is in the knee and most often located in the patello-femoral compartment, although it can be in any compartment. If you-re unsure of the location of the plica that your surgeon documents, ask the physician specifically which compartment he addressed.

1 Compartment Leads to 1 Code

Payers usually interpret the NCCI edits to mean that you may report only one code for each compartment the surgeon addresses. For example, this problem often occurs when a patient has a meniscal tear and a concomitant osteochondral defect in the same compartment, usually a defect on the medial femoral condyle.

During arthroscopy, most surgeons will address both problems, performing a medial meniscectomy (or repair) and shaving the osteochondral defect, termed a -chondroplasty- for coding purposes. The codes for these are 29881 or 29882, and 29877.

But NCCI bundles 29877 into both 29881 and 29882, and you cannot report them together if the physician performs the procedures in the same compartment.

Exception: If a non-Medicare patient has a medial meniscal tear and a lateral femoral osteochondral defect, you could report 29881 or 29882 with 29877-59 for the chondroplasty, indicating that you can bypass the NCCI edit because the surgeon addressed two different compartments.

If Medicare covers the patient, you should report 29881 or 29882 with G0289 (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/ shaving of articular cartilage [chondroplasty] at the time of other surgical knee arthroscopy in a different compartment of the same knee). Again, the surgeon must perform the chondroplasty in a different compartment if you want to collect.

Documentation Is the Key to Reimbursement

Thorough documentation is critical in either case to prove fully that the surgeon performed the procedures in different compartments.

Tip: A great way to ensure the maximum reimbursement is to have the surgeon dictate notes using separate paragraphs for each compartment, with a header on each paragraph, and placing the code at the end of each paragraph. It looks something like this:

- Patello-Femoral Compartment. The patello-femoral compartment was inspected fully. No abnormalities were found.

- Medial Compartment. In the medial compartment, a flap tear of the medial meniscus was found. This was excised using a motorized shaver (29881).

- Lateral Compartment. In the lateral compartment, no meniscal tear was noted. An osteochondral defect was found on the lateral femoral condyle. This was debrided to a smoother surface using a motorized shaver (29877-59).

- Intra-Articular Notch. The intra-articular notch was inspected fully and a probe used to test the ACL and PCL. No abnormalities were found.

This method achieves maximum ethical reimbursement for knee arthroscopies. Learn your knee compartments and have your surgeons document them separately, and you can optimize your op notes to ensure reimbursement.