Advanced Search

Orthopedic Coding Alert

Meet the Coding Challenges of ACL Reconstruction and Revision

Published on Wed May 01, 2002

"

There are several methods by which a physician can achieve anterior cruciate ligament (ACL) revision or reconstruction, but only two codes to describe them. Arthroscopic or open ACL repair, thermal ACL shrinkage, revisions, and ACL repair along with other knee procedures make for coding headaches and reduced reimbursements, but you can avoid both through thorough documentation and correct modifier use.

What Is ACL?

The ACL is located in the center of the knee, behind the kneecap, and runs from the femur to the tibia. As the major stabilizing ligament of the knee, it prevents buckling and instability.

ACL problems are typically the result of pivoting, twisting, hyperflexion and hyperextension injuries to the knee. Individuals who ski, play football or in-line skate frequently injure themselves in this manner. An ACL injury can be relatively minor, such as a pull or stretch, or severe, where the ligament is partially torn or completely ruptured. Minor ACL injuries can be treated nonoperative-ly with physical therapy and bracing, and incomplete tears can be repaired without the use of graft material, whereas torn ACLs have to be reconstructed with the use of autograft or allograft tissue.

Repair of the ACL involves using sutures to anchor the torn ligament to its original point of attachment on the femur to set it back into its correct anatomic site. Although the procedure can be done by open repair, it is most often accomplished arthroscopically.

An emerging procedure, thermal ACL shrinkage, is used to stretch injuries of the ligament that do not require tendon graft. With arthroscopic guidance, a thermal probe is inserted into the knee, where it heats the damaged ligament to shrink and tighten it. The stretched ligament shrinks to its normal size, thus returning stability to the knee.

Reconstruction of a torn ACL is significantly more involved and is accomplished through one of three methods, all of them arthroscopic:

  • A portion of the patellar tendon is harvested (autograft) to create the new ACL.
  • Two small portions of hamstring tendon are harvested (autograft) to create the new ACL.
  • Donor tendon, or allograft, is used to create the new ACL.

    In all three methods, the new tendon is inserted through holes drilled in the tibia and femur, pulled through, and secured in position with bio-absorbable or metal screws. When the tendon is harvested from the patient, harvesting takes place at the same time as the reconstructive surgery.

    Limited Coding Options

    Several codes describe open ACL repair and reconstruction, but with the advent and domination of arthroscopy, the codes are largely obsolete. And arthro-scopic ACL repair or reconstruction has only one code: 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction).

    According to the American Academy of Orthopaedic Surgeons' (AAOS) Complete Global Service Data Guide, 29888 includes the following procedures:

  • minor synovial resection for visualization (e.g., 29875)
  • articular shaving, debridement, chondroplasty (e.g., 29877, 29879)
  • notchplasty (debridement of the intercondylar notch of the femur)
  • ACL stump removal (replacement of ligament)
  • synovectomy and fat-pad resection (e.g., 29875, 29876)
  • intra-articular ligament reconstruction (e.g., 27428, 27558)
  • harvesting of graft (20924)
  • diagnostic arthroscopy (29870)
  • additional portals or enlarging portals
  • internal fixation of graft.

    The scarcity of codes for the ACL repair reveals the reimbursement challenge. Arthroscopic ACL reconstruction is a much more involved procedure than arthroscopic ACL repair" " says Susan Callaway CPC CCS-P an independent coding consultant and educator based in North Augusta S.C "yet there is just one code to describe the procedure." Regardless of whether the physician has to graft tendon and remove the ACL stump or simply anchor the stretched ACL to the patella without need for grafting or removal of damaged tendon the code is the same. "This is an obvious frustration to surgeons and coders " she adds "because the range of work in a repair versus a reconstruction is wide." Practices do not receive any less reimbursement when they bill 29888 for a repair but they similarly do not receive additional reimbursement when they bill 29888 for a reconstruction.

    ACL Revisions

    ACL revision surgeries occur when an initial repair or reconstruction fails or the patient reinjures his or her ACL. Because of the already surgically altered operative field ACL revisions are more complex than repairs or reconstructions. Special complexities associated with a revision include the following:

  • the need to remove the old graft material screws and suture anchors
  • possible need to revise the femoral and/or tibial tunnels (the drill holes made during the first ACL surgery)
  • possible need to harvest graft from a distant site sometimes even the opposite knee
  • presence of scar tissue complicating the surgical dissection.

    Coders reporting ACL revisions encounter the same limitations as they do for reconstructions essentially one code to describe any arthroscopic ACL procedure. When revisions include complexities like those listed above the coding option is to append modifier -22 (Unusual procedural services) to 29888. Doing so indicates to the payer that extra work was performed above and beyond the normal scope of the procedure. However modifier -22 should be used only if written documentation including an operative report intraopera-tive photos and a letter from the surgeon verify that the extra work was done. The surgeon should explain the specific complications he or she encountered (removal of graft material distant graft site etc.) and estimate how much more difficult (e.g. 20 percent 30 percent) the procedure was as a result of this altered surgical field. This percentage will help the payer to determine what extra percentage of the normal fee to reimburse for the extra work.

    Thermal Shrinkage

    Thermal ACL shrinkage is a surgical anomaly when compared to other ACL procedures because it is minimally invasive and generally much faster than a traditional or arthroscopic ACL repair. Because the amount of work with a thermal shrinkage is far less than that involved with arthroscopic ACL repair (there are no sutures and only one incision for the scope) experts agree that the unlisted arthroscopy code (29999 Unlisted procedure arthroscopy) is appropriate to submit for this claim. As with every use of an unlisted procedure code documentation should include a thorough description of the procedure an operative note and a letter from the surgeon.

    • "

    Other Articles in this issue of

    Orthopedic Coding Alert

    View All