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 [...]