Orthopedic Coding Alert

Orthopedic practices that use allograft should be sure to avoid the CPT Codes with descriptors that state, "includes obtaining graft," because these codes apply only to procedures involving graft harvest from the patient.

Many orthopedic coders are confused about which code they should use when the orthopedist doesn't obtain the graft, as is the case with allograft. Some coders are tempted to use one of the codes listed in CPT for allograft procedures, such as 20930 (Allograft for spine surgery only; morselized), but you should use these codes only when the graft is not already listed as part of the main procedure.

Autograft, the most common grafting material, is made up of bone obtained from the patient's own body. Allografting uses a graft obtained from a cadaver, and the bone is frozen until use.

According to Shelli J. Jones, medical specialty coder at Raleigh Orthopaedic Clinic in N.C., only about 5 percent of her practice's grafts are performed using allograft, but the coding implications are very different from when autograft is used. "When our orthopedists perform grafts using allograft rather than a graft obtained from the patient, we can only bill the surgical procedure code in our case, normally a spine surgery code but we cannot bill separately for the graft since no harvesting was involved."

For instance, suppose a patient with a dislocated shoulder receives a graft using allograft during dislocation repair surgery. According to Denise Paige, CPC, president of the American Association of Professional Coders' Long Beach Chapter, "If the CPT descriptor says 'includes obtaining graft,' it means that graft is taken from the patient (for instance, an autograft) through a separate site or incision and should be billed using 23552 (Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft [includes obtaining graft]). If the graft is an allograft (not harvested from the patient), then the correct code would be 23550 (Open treatment of acromioclavicular dislocation, acute or chronic)."

There are rare situations when the work to prepare the allograft is particularly complicated, Paige reminds coders. If the documentation supports it, she suggests appending modifier -22 (Unusual procedural services) to 23550 rather than erroneously upcoding to 23552. "Normally, however," Paige states, "the allograft work is considered included in 23550."

This advice leaves orthopedic coders wondering why the separate allograft codes (20930-20931) even exist, but these codes can be essential when the orthopedist performs allo-grafting with procedures that do not have grafting included in the descriptors. For instance, orthopedists frequently use allografting during arthrodesis procedures (22548-22632), in which case 20930 or 20931 can also be billed.

Autografting can be billed separately as well, as long as the main surgery code doesn't include grafting. CPT uses two separate phrases for procedures where autograft material is used: "with autograft (includes obtaining graft)" for code 25405, and simply "with autograft" for code 25425. When the descriptor does not state "includes obtaining graft," a separate code (20900 or 20902) may be reported as long as the graft came from a distant site or separate incision.

For instance, if the surgeon performs 25628 (Open treatment of carpal scaphoid [navicular] fracture, with or without internal or external fixation) and harvests a bone graft from the patient's wrist, you can code for the graft separately using 20900 (Bone graft, any donor area; minor or small) or 20902 (Bone graft, any donor area; major or large).

Because graft procedures can be performed only in conjunction with other procedures, CPT designates grafting codes as "modifier -51 exempt." The value for these services already takes into account the combination with other codes and is adjusted accordingly. Never append modifier -51 (Multiple procedures) to these codes, because doing so will cause additional, unnecessary reduction in payment.

Most Medicare payers accept only one bone graft code per operative session. If an autograft and allograft are performed during the same procedure, report only the more extensive procedure (normally this will be the autograft).