Orthopedic Coding Alert

Read policies carefully for OATS, mosaicplasty procedures

Knee surgery remains one of the top procedures for orthopedic surgeons, but coders can find it difficult to navigate the codes for new procedures and for combination surgeries. If you could use a quick knee coding primer, we-ve got just the information you need.
 
You Can Report ACL Repair With Meniscectomy

Patients who suffer complex sports injuries often present with a combination of problems. Your surgeon might repair not just the medial or lateral meniscus but also ligament injuries. The good news is that you can usually report both procedures.

For example: Suppose your surgeon repairs a torn anterior cruciate ligament (ACL) and a torn medial meniscus on a Medicare patient. He also performs chondroplasty on the lateral meniscus.

Problem solved: You can report all three surgeries, as follows:

- 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) for the ACL repair.

- 29882-51 (Arthroscopy, knee, surgical; with  meniscus repair [medial OR lateral]; Multiple procedures) for the medial meniscus repair.

- 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) for the lateral chondroplasty.

Because the National Correct Coding Initiative (NCCI) does not bundle these codes together, you do not need to append modifier 59 (Distinct procedural service) to any of them.

Tip: If you-d like a quick reminder of where the knee structures lie, review our chart in this issue entilted  "Let This Chart Help You Select Accurate Knee Repair Codes".

Buckle Down on ACI Specifics

In 2005, CPT introduced 27412 (Autologous chondrocyte implantation, knee), but some coders are still unfamiliar with this fairly new procedure. Here is a quick lesson on ACI coding.

-Patients are usually referred for autologous chondrocyte transplantation if they remain symptomatic after already having surgery for an articular cartilage problem,- says Kathy Tischner, CPC, CCP, coder at Johns Hopkins Orthopaedics at Good Samaritan Hospital in Baltimore, Md. -Once the patient/surgeon decides this is the best option, an arthroscopic biopsy will be performed- (29870, Arthroscopy, knee, diagnostic, with or without synovial biopsy [separate procedure]).

Note: Some payers prefer HCPCS code S2112 (Arthroscopy, knee, surgical for harvesting of cartilage [chondrocyte cells]) when the surgeon harvests the cells.Ask your insurer which code you should report.

The surgeon performs the arthroscopy with a biopsy to harvest normal cartilage from a low-load-bearing area within the knee, Tischner says. -The chondrocytes are sent to a lab to be isolated from the cartilage matrix then cultured for three to four weeks. Once the viable cells are returned in suspension, they are now ready for surgical implantation.-

The surgeon then performs a knee arthrotomy with any necessary debridement, and harvests a periosteal flap, usually along the medial aspect of the tibial ridge, using a template drawn from the defect, Tischner says. The surgeon sutures the graft into place and injects a gel-like medium containing the cultured chondrocytes into the area. -Then the surgeon may perform a water test to ensure no fluid is escaping. The wound will then be lavaged and closed in layers.-

How many codes? You should report 27412 for the implantation itself, but can you report the tissue graft as well? In most cases, the answer is yes, Tischner says.

The NCCI bundles 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]) into 27412 to prevent physicians from billing for both procedures if they perform them during the same surgery.
 
But because the surgeon normally harvests the chondrocytes weeks ahead of time, you can report 20926 separately along with 27412. Be sure to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 27412 so the insurers know that you planned the ACI ahead of time.

Payers Differ on 29866 Reimbursement

CPT also introduced 29866 (Arthroscopy, knee, surgical; osteochondral autograft[s] [e.g., mosaicplasty] [includes harvesting of the autograft]) and 29867 (Arthroscopy, knee, surgical; osteochondral allograft [e.g., mosaicplasty]), last year, but some coders tell Orthopedic Coding Alert that they have problems trying to collect for these procedures.

What the procedure involves: This surgery is similar to the ACI discussed above, but it requires only one surgical visit to complete the procedure. During the osteochondral autograft, the surgeon takes one or several cylindrical osteocartilaginous grafts from peripheral and non-weight-bearing areas of the knee (donor site) and transfers them to the prepared damaged area (recipient site), usually under arthroscopic visualization.

Surgeons may use different techniques to perform the procedure, and each technique bears a different manufacturer's name. Surgeons most commonly refer to osteocartilaginous transfers using one these instrumentation brands: OATS (Arthrex), COR Systems (DePuy), and Mosaicplasty (Smith and Nephew).

Reimbursement can be sketchy for 29866 and 29867 claims. Although CMS assigned 27.65 relative value units (RVUs) to 29866 in 2006, you are not guaranteed payment for this service by your Medicare carriers. Some Medicare payers (such as Cahaba) consider these claims on a case-by-case basis, while others (such as Noridian) consider the procedure ineffective and will deny all claims for 29866.

Private payers may offer more flexibility. Aetna's policy states that it considers autologous osteochondral mosaicplasty and osteochondral autograft transfer system (OATS) experimental and investigational, but it also states, -Aetna considers osteochondral autografts medically necessary for repair of small (less than or equal to 1 cm) focal chondral defects of articulating cartilage that are causing significant symptoms that have not been relieved by appropriate nonsurgical therapies.-

-Even though Aetna's policy states they consider it experimental, if you read the policy statement, there are conditions in which it is approved,- says Jean M. Marsicek, practice manager at Orthopaedic Associates of Milwaukee in Wisconsin.

When faced with a denial for billing 29866 to repair a small focal chondral defect of articulating cartilage, -Wewere able to appeal and receive payment by submitting records, op notes, scope pictures, etc. It helps to have a very thorough surgeon who details everything.

-Read the policy, verify that you have documentation to support the medical necessity, and submit for appeal if you did not get preauthorization for the procedure prior,- she says.