Orthopedic Coding Alert

Do you know how to handle coding for more than one arthroscopic service performed at a single surgical session? Your reimbursement depends on it.

The scenario is familiar, but the coding requirements may not be: The orthopedist performs arthroscopic shoulder surgery (29819), an acromioplasty (29826) and a distal clavicle resection (29824). Because these codes are in the same family, Medicare's multiple-endoscopy rule, not the standard multiple-procedures rule, governs your reimbursement.

In CPT, a "family" of codes is designated by a non-indented code followed by a group of indented codes. For example, Utah Medicare's March 2003 Part B Update lists 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy [separate procedure]) as the base code in the endoscopic family that includes codes 29806-29826. (See our article "Get to Know Your Families" for a list of the arthroscopic families.)

Medicare carriers would reimburse claims for 29819 (Arthroscopy, shoulder, surgical; with removal of loose body or foreign body), 29826 (... decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) and 29824 (... distal claviculectomy including distal articular surface [Mumford procedure]) using CMS' multiple-endoscopy rule instead of the multiple-procedures rule.

Differentiate Family From Friends

Most orthopedic coders are all too familiar with Medicare's "multiple surgeries" regulation. According to section 15038 of the Medicare Carriers Manual (MCM), if you report two or more surgical procedures (not in the same family) on the same day, Medicare will pay the first procedure at the full relative value unit (RVU) allowable rate but will discount the second through fifth procedures by 50 percent.

Some carriers automatically append modifier -51 (Multiple procedures) to these claims, although other payers require the practice personally to append modifier -51 to the second and subsequent procedures.

Medicare maintains a separate payment rule, however, for multiple endoscopies. The MCM states, "For multiple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy." This means that if the base endoscopy has 15 RVUs, your primary endoscopic procedure carries 25 RVUs and your second endoscopic procedure from the same family has 20 RVUs, Medicare will only pay five RVUs for the second procedure, because this is the difference between the base procedure and the lesser-valued surgical endoscopy.

Pick One Rule, Not Both

"Reimbursement subject to Medicare's multiple-endoscopy rule is not also subject to the multiple-procedures guidelines," says Dolores Kesemere, billing manager at Professional Orthopedic Associates in Tinton Falls, N.J. If your carrier reduces your claim based on the multiple-endoscopy rule and also takes a multiple-procedures discount off of that amount, you should appeal your claim and ensure that the carrier issues you additional reimbursement.

To avoid receiving a "double discount," most consultants advise against appending [...]