Orthopedic Coding Alert

Coding multiple arthroscopic knee surgeries where more than one procedure is performed in the same operative session is challenging even for experienced orthopedic coders. Subtle differences in where the surgery is performed within the knee joint determine whether it is appropriate to report a procedure. Coders must be judicious about reporting more than one code to describe arthroscopic knee procedures because many arthroscopic procedures are considered part of another, more comprehensive procedure. But, at the same time, knowing when it is appropriate to report more than one surgery can positively affect the bottom line.

Multiple Procedure Basics

The most basic problem with coding multiple knee arthroscopies is that many surgeons prefer to perform bilateral procedures when both knees need surgery. There are three compartments in the knee, the medial, lateral and patellofemoral. The number of compartments affected in surgery determines the codes that can be reported.

The AMA and CPT provide minimal instruction on bundled arthroscopic procedures. Guidelines are limited to stating that a diagnostic arthroscopy (29870 for the knee) is always included in surgical arthroscopies and cannot be billed separately. They also state that an open procedure performed in conjunction with an arthroscopy requires modifier -51 (multiple procedures).

Further guidelines can be found within the narratives of several codes, specifically 29875 (arthroscopy, knee, surgical; synovectomy, limited [e.g., plica or shelf resection] [separate procedure]) and 29884 ( with lysis of adhesions, with or without manipulation [separate procedure]), that have separate procedure designations. CPT defines separate procedures as those that are commonly an integral component of another more comprehensive one. Separate codes should not be reported in addition to the procedure of which it is considered a component part. However, when a procedure is so designated, and is carried out independently or considered to be unrelated to the other procedure(s), it can be reported separately with modifier -59 (distinct procedural service). CPTs rules for modifier -59 indicate that the distinct procedural service may represent a different procedure, a different site or excision or a separate injury. This makes even justified unbundling in knee surgeries a difficult task with payers because there are no definitive rules as to when you can unbundle an item. And because virtually all payers and most coders err on the side of conservative coding, opportunities for additional fair revenue may be lost.

A Coding Primer for Knee Arthroscopies

Although there are many combinations of arthroscopic knee surgeries, Heidi Stout, CPC, CCS-P, coding and reimbursement specialist at University Orthopedic Associates in New Brunswick, N.J., identifies several common surgeries involving multiple procedures and how to code for them to receive optimal payment.

Arthroscopic-aided anterior cruciate ligament repair/augmentation or reconstruction with patellar tendon graft (ACL repair with [...]