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 tendon graft).

In an ACL repair (29888, arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction), a tendon graft is inserted in place of the torn ligament. If the tendon graft is harvested locally, meaning it comes from the patients hamstring at the same operative site, 29888 is the only code that can be submitted.

If the graft is harvested from the opposite knee, however as may be necessary in cases of severe degeneration and damage 29888 is reported with 20924 (tendon graft, from a distance [e.g., palmaris, toe extensor, plantaris]). Modifier -59 should be appended to 20924 because a separate incision was required to harvest the graft. You will often have to fight for the additional reimbursement after the fact, Stout says. Most carriers bundle 20924 into 29888, which is appropriate when the graft is harvested at the surgery site.

Arthroscopic-aided anterior cruciate ligament repair/augmentation or reconstruction with repair of medial meniscus and partial lateral meniscectomy.

On three separate lines, report 29888, followed by 29882-51 (arthroscopy, knee, surgical; with meniscus repair [medial OR lateral]) and 29881-59 (arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]). Use of the -59 modifier is important here because most carriers will bundle 29881 and 29882 together, Stout says. This is done on the basis that you cannot repair and excise the same meniscus. But because the medial meniscus is repaired and the lateral meniscus is excised, both codes are reimbursable. The operative note should clearly indicate that both the lateral and medial meniscus were affected. And, although the -51 modifier is becoming less necessary in coding, Stout and her surgeons agree that this example supports use of modifier -51 because 29888 and 29881 do not share the same base code, meaning they are not part of the same indented group of codes (as are 29881 and 29877 [arthro-scopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)], for example).

Arthroscopic partial medial meniscectomy with debridement of lateral femoral condyle.

In this example, 29881 and 29877 can be reported together, with modifier -59 appended to 29877. The distinction, Stout explains, is that the meniscectomy and debridement were performed in separate compartments of the knee. Under these circumstances, AAOS [American Academy of Orthopedic Surgeons] guidelines support using both codes, she says. However, if the medial femoral condyle was debrided, it would be inappropriate to report 29877.

Some payers may look at the debridement (29877) as always included with other arthroscopic knee procedures, explains Susan Callaway, CPC, CCS-P, a North Augusta, S.C.-based independent coding consultant and educator with extensive experience in orthopedics. A carrier might assume that because the surgeon was in the [knee] area anyway, saw some uneven cartilage and smoothed it over, that should just be included in the primary procedure. But, because the debridement took place on a separate compartment from the one being operated on, this is a separate procedure that can be billed as such, she says.

Use -59 With Care and Certainty

As Callaway illustrates in the debridement issue, every carrier will approach multiple procedures with a different set of rules. This makes for obvious challenges when carriers wont pay for a separate procedure, but surprisingly, even bigger challenges when they will pay. Callaway explains that many carriers will automatically unbundle when they see the -59 appended to a code. Although this might initially appear to be a boon for reimbursement, it places a greater responsibility on coders to make sure they are asking for the right thing and following CPT and HCFA rules. You cant force payment with the -59 modifier, Callaway says, even if you know you will get it with no questions asked.

She cites the recent example of a physician who was inappropriately appending the -59 modifier to multiple procedures, but getting paid every time. The -59 is a red flag for an audit to begin with, Callaway says. If and when this surgeon is audited, he is in for a world of trouble because of those inappropriate claims. For Medicare, in particular, it is easy to get payment using modifier -59, but if those claims were submitted incorrectly in the first place, and an audit ensues, the surgeon(s) will likely be accused of fraud, and the legal costs could cripple the practice.

To be on the safe side, use the -59 modifier only when you are certain that documentation, such as operative notes and excerpts from CPT or the AAOS Global Service Data Guide, supports billing for multiple procedures. For procedures that are not bundled to begin with, there is no need to report modifier -59. Increasingly, the -51 modifier is redundant as well, as many payers no longer accept it and already make reductions on the second, third code, etc. Medicare already reduces payment for multiple scope procedures, Callaway says, Therefore, I would never report multiple arthroscopies with modifier -51 appended to them. Youre going to get the reduction anyway, and with the -51, they may take an even greater reduction if it is placed on the wrong code.

The following are some examples where coders may be tempted to report more than one code and append the
-59 modifier to the second code. However, a careful study of what was done and coding resources reveal that these are single-code procedures.

Arthroscopic partial medial meniscectomy with debridement of anterior cruciate ligament stump.

This should be reported using 29881. Stout says that many surgeons will incorrectly report 29877 in addition to 29881, but according to AAOS guidelines, the ACL debridement is included in the meniscectomy.

Arthroscopic partial lateral meniscectomy with excision of plica.

This should be reported using only 29881. Stout says that many surgeons tend to unbundle 29875, but this is incorrect. Code 29875 has a separate procedure designation because most arthroscopic knee surgeries involve a limited synovectomy. The synovium is resected to permit optimum visualization of the knee joint and is an integral part of the larger procedure.