Orthopedic Coding Alert

Receiving fair payment for multiple surgical procedures is a frustrating dilemma for orthopedic offices. A common situation occurs during arthroscopic knee surgery where additional procedures are performed in separate pockets during the same surgical session. If the coder simply lists all the procedures on the billing form, the claim is often denied, or the coder ends up having to make time-consuming (and possibly futile) justifications and appeals. When and how can you bill for multiple arthroscopic procedures during the same surgery and get paid?

Understand Bundling and Unbundling

First and foremost, every orthopedic coder needs a good understanding of bundling. Every surgical procedure has a global surgical package (where several items are bundled together), says coding consultant Catherine Brink, CMM, CPC, president of HealthCare Resource Management, Inc. of Spring Lake, NJ. Normally speaking, there are certain steps that are taken during the course of a surgical procedure that cannot be unbundled, she explains. (See list included at the end of this article.)

In addition to the steps that are bundled together, certain procedures performed at the same time are lumped together into one code. While each procedure may have its own code, it is not unusual for both federal programs and private third-party payers to count two separate surgical procedures as a single bundled one. These bundling edits are listed in what is commonly referred to as the Correct Coding Initiative (CCI) or the National Correct Coding Policy. These coding edit guidelines were created at the request of the Health Care Financing Administration (HCFA) through Administar. Administar publishes these edits and sells them to insurance carriers and providers. HCFA and other third-party payers follow these bundling edits closely.

Tip: The CCI edit guidelines can be obtainable through your coding manual supplier.

To the orthopedic practice, bundling presents as a huge challenge. This is especially true in the case of arthroscopic knee procedures, when more than one procedure is performed on the same joint but in a different area. Justifying a second or third procedure during the same surgery will depend on those performed and reported, the modifier used, diagnosis codes applied and documentation.

When is it Really an Additional Procedure?

The answer to When is it really an additional procedure? depends on the specific procedures involved. For example, Carolyn Forrester, office manager for the Kernodle Clinic, Burlington, NC, asks:

An outside auditor told our office we could not bundle 29880 (arthroscopy of the knee with meniscectomy, both medial and lateral, including any meniscal shaving) and 29877 (debridement/shaving of articular cartilage or chondroplasty), even if the procedures were in different compartments. Are we right or is the auditor?

In the above case, HCFA and other third-party payers would normally bundle the two surgical procedures together as one code (i.e. 29880 and 29877 would be bundled into 29880). Even though the meniscal shaving was performed both medially and laterally, both compartments are typically included in the code 29880.

However, if the surgeon performs a chondroplasty in two compartments (medial and lateral), multiple drilling or abrasion arthroplasty, then reporting a secondary procedure is warranted and justified through code 29879 (arthroscopy of the knee, abrasion arthroplasty, includes chondroplasty where necessary, or multiple drilling). Therefore you would report the 29880 and then 29879.

The bottom line is that when more than one major procedure is performed, each should be reported separately. Only when procedures are deemed incidental or considered necessary to accomplish the comprehensive procedure should they be bundled. But because there are always exceptions in coding, its wise to check every multiple procedure with a current copy of the CCI edits.

Lets look at what procedures are included in a major knee arthroscopy (29880) they would include (per CCI edits):

Diagnostic arthroscopy, knee (29870)

Minor synovectomy resection for visualization
(one compartment) (29875)

Synovial biopsy (29870)

Debridement and/or shaving of meniscus (29881, 29880)

Plica and/or synovial resection (29875)

Inspection of joint (29870)

Additional portal(s) or enlarging portal(s) (no separate code - part of any arthroscopy)

Knee lavage and/or drainage (29871)

Additionally, per the American Academy of Orthopedic Surgeons Global Service Data for Orthopaedic Surgery, also included would be:

Debridement and/or shaving of cruciate stump (29875)

Meniscal tissue removal (29881, 29880)

Articular shaving, debridement and/or chondroplasty in the same compartment (29877, 29879)

Those services NOT bundled in the package would be removal of loose body (non-meniscal) or foreign bodies through a separate incision (29874), per the AAOS manual which differs from the CCI edits. You can see how this distinction can confuse the novice and seasoned coder, physician and insurance carriers alike.

Using Modifiers

Using the correct modifier is essential in preventing denials when coding for arthroscopic procedures.

For example, some orthopedic offices attach the modifier -51 to 29877 (arthroscopy of the knee, debridement/shaving of articular cartilage - chondroplasty). This modifier indicates that the debridement was a multiple procedure, performed on the same day, by the same physician. This would be an incorrect use of the -51 modifier, however, as most third-party payers would assume that the orthopedist is unbundling and charging for a procedure that is usually included in another arthroscopic procedure. This claim would be denied for unbundling an integral part of code 29880 (arthroscopy of the knee with meniscectomy, both medial and lateral, including any meniscal shaving).

The 59 modifier (distinct procedural services) may be used but only when no other modifier applies. This modifier is used when the procedure in question is generally included or bundled in another major procedure or separate site or separate excision.

Tip: Modifier -59 should only be used as a last resort, as some payers are refusing to accept it altogether. It is always advisable to check with your carrier for specific rules and guidelines on its usage.

Correct Supporting Diagnosis Codes

One of the most important aspects to getting paid for multiple arthroscopic procedures is solid diagnosis code support. Payers will be looking closely at these surgeries. Remember, its the diagnosis code that drives the medical justification for the procedure. If your diagnosis doesnt accurately describe the reason for the additional procedure, then the insurance carrier has no medical reason documented to justify your claim. The only way to truly be sure of how to bill these claims is to justify each line item (CPT code) with its own particular diagnosis code.

For example, 29880 (medial and lateral meniscectomy) requires either an acute or chronic diagnosis that most accurately describes how or when the patient acquired this particular problem that required surgical intervention. If the patient had an accident, or acute onset, then 836.0-836.2 (tear of medial, lateral or unspecified meniscus) would be appropriate to use.

Tip: Remember, it is very important to enter the date of the accident or onset of the problem when using an 800 or 900 diagnosis code.

For code 29877 (surgical debridement/shaving of articular cartilage, chondroplasty), a different diagnosis must be used to describe or substantiate that a separate procedure was necessary, or why it should be considered separately as an unbundled procedure. The modifier -59 would be used if the procedure(s) were generally included as an integral or incidental part of another procedure performed. For instance, if the diagnosis 836.0-836.2 was used or reported, then the subsequent procedure would be considered as part of the major one (29880). However, if the problem was something totally unrelated to the major procedure, such as osteoarthritis or osteomyelitis, then the separate surgery would be medically justified. The second procedure would be reported as 29877-59 with 730.06-730.26 (osteomyelitis) or 715.16-715.96 (osteoarthritis) attached as a diagnosis.

Documentation Critical

Finally, no matter what codes you use, they should always agree with the documentation in the medical chart or operative report. If the medical chart fails to account for a surgical procedure, then you cant legally bill for it. Again, the operative report should be an accurate representation of the procedure(s) the surgeon performed, and the claim should then reflect the same information in reporting these services. It is just as important to have the procedures listed in the heading of the operative report as in the body of it. If an insurance carrier requires that the report be sent for an appeal or for a prepayment review, then the documentation must support the charges being filed.

Typical Bundled Surgical Steps Preoperative care relating to the procedure Cleansing, shaving and preparing of the skin Local, topical or regional anesthetic administered by physician performing the procedure Surgical approach, including identification of anatomical landmarks, incision, evaluation of the surgical field, simple debridement of traumatized tissue, lysis of simple adhesions, isolation of neurovascular, muscular, bony and other structures limiting access to the surgical field Surgical cultures Wound irrigation Insertion and removal of drains, suction devices, dressings, pumps into same site Preoperative, intraoperative and postoperative documentation, photos, drawings, dictation Postoperative care related to the procedure and returning the patient to the pre-procedure state Application of initial dressing, orthosis, continuous passive motion (CPM), splint or cast, including traction, except where specifically excluded from global package (e.g., 15852, 29000-29799). Intraoperative services not included in the global service package would be: Surgical supplies and medication (e.g., codes 99070, HCPCS Level II codes), unless exempted by existing HCFA policy, and Complicated wound closure, or closure requiring local or distant flap coverage and / or skin graft, when appropriate (e.g., 13160, 13300, 14000-14350, 15000-15401, 15570-15776).