Orthopedic Coding Alert

Version 12.1 focuses on knee, spine and debridement claims

If you have regularly reported 22612 and 22630 together, brace yourself: The latest round of National Correct Coding Initiative edits, which became effective on April 1, makes it clear that you shouldn't report them separately unless you perform a distinct procedural service.

Fusion Code Pairs Take a Hit

If your surgeon performs a posterolateral fusion at the same time he performs an interbody fusion, you could have trouble collecting for the interbody procedure.

Old way: In the past, you probably reported the fusion procedures with 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) and 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).

New way: NCCI now bundles 22630 into 22612 as -mutually exclusive procedures,- but you can use a modifier to separate the edit if the surgeon performs distinct procedural services.

But spine surgeons aren't taking the news sitting down, because the interbody fusion can sometimes take well over an hour, and therefore they expect to get paid for it. In some instances, spine surgeons find it clinically necessary to perform both procedures. For instance, many surgeons customarily supplement a PLIF or TLIF with a posterior fusion.

What you can do: Spine coders should contact their local and national associations to ask how they can effect change to eliminate this new edit.

Beware What You Report With 27415

The NCCI version 12.1 now bundles several orthopedic codes into 27415 (Osteochondral allograft, knee, open). For instance, knee arthroscopy codes 29866-29867, 29870, 29874 and 29877 are now all bundled into 27415.

Rationale: -Allograft refers to tissue obtained from another source, while autograft is the term for tissue obtained from the patient,- says Paul Kosmatka, MD, an orthopedic surgeon at SMDC Orthopedics in Duluth, Minn. Arthroscopy is not part of the procedure described by 27415, he says, but if the surgeon does perform arthroscopy, -it is considered insignificant and therefore bundled into code 27415.-

Caveat: If the surgeon performs a distinct and separate service along with the allograft, he can append a modifier, such as 59 (Distinct procedural service), to the arthroscopy code. For example, if the surgeon treats a meniscal lesion in a separate compartment from where he implants the allograft, he can append modifier 59 to the meniscal lesion treatment code, Kosmatka says.

The new edition of NCCI also bundles the following codes into 27415:

- Debridement codes 11010-11012
- Major joint/bursa injection code 20610
- Deep implant removal code 20680
- Knee arthrotomy with foreign-body removal, exploration or drainage code 27310
- Knee arthrotomy codes 27330-27331
- Partial bone excision code 27360
- Knee joint manipulation code 27570.

Spine Edits Shouldn't Shock

The NCCI debuted a number of edits that will make spine coders do a double-take, mainly because the edits affect laminotomy, laminoplasty and laminectomy claims. So if you don't look at your terms carefully, you could get confused.

For example, version 12.1 now bundles cervical laminotomy codes 63020 and 63040 into cervical laminoplasty codes 63050-63051.

Although the NCCI lists over a dozen edits that affect spine codes, you probably won't suffer a big kick in the wallet from these new laminotomy/laminoplasty bundles. -The new edits should not affect our practice,- says Lisa St. Germain, CPC, coding specialist at Orthopaedic Specialists of the Carolinas.

-We would only bill any combination of 63020, 63040 and 63050 code groups if the surgeon performed the surgeries at different vertebral levels,- St. Germain says.

Likewise, the NCCI now bundles 63265 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical) into 63051 (Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; with reconstruction of the posterior bony elements [including the application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, mini-plates), when performed]).

Again, because laminectomy and laminoplasty are such completely different procedures, surgeons probably wouldn't perform them at the same spinal level during the same session. If the surgeon performs the procedures at separate levels, you can append modifier 59 to the bundled code.

Here's the difference: During laminectomy, the surgeon cuts out or removes the lamina. With laminotomy, the surgeon incises or opens the ligaments between the laminae. During laminoplasty, the surgeon splits the laminae and then opens them up to reduce pressure on the spinal cord and nerve roots and holds the position in place with bone grafts or a fixation device.

Coders Expected Knee Joint Manipulation Bundle

Coders who see a lot of knee surgery patients should take note of a new code pair that may change the way you bill but shouldn't affect your bottom line too severely.

NCCI now bundles joint manipulation code 27570 into both 29866 (Arthroscopy, knee, surgical; osteochondral autograft[s] [e.g., mosaicplasty] [includes harvesting of the autograft]) and 29868 (Arthroscopy, knee, surgical; meniscal transplantation [includes arthrotomy for meniscal insertion], medial or lateral), but many coders don't foresee this to be a problem.

-I don't bill 27570 with any arthrotomy, arthroplasty or arthroscopy of the knee,- St. Germain says. -I would report 27570 if the surgeon performed it alone or on the contralateral knee. In my opinion, these weren't bundled in NCCI versions because the codes were new for 2005 and it was simply missed.-  
 
Look for New Chondrocyte Implant Bundles 

The new edition of NCCI also includes a few edits that have orthopedic coders scratching their heads. For example, the NCCI now bundles 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) into 27412 (Autologous chondrocyte implantation, knee).

Although the NCCI formally cites -standards of medical/surgical practice- as the reason for this new code pairing, most orthopedic coders can't figure out why the NCCI would bundle these codes together because surgeons don't often have to remove hardware before performing the chondrocyte implant.

-If a patient had prior treatment using internal fixation, the instrumentation would be removed prior to performing the chondrocyte implantation,- says Denise Reynolds, CPC, orthopedic coder at the Nemours Clinic. -And if 20680 wasn't previously listed as an edit with 27412, then I could see an inexperienced coder or biller submitting a claim for both codes in error.
 
-We all refer to NCCI for our coding, but someone new at coding may not know that the removal of internal hardware is necessary to accomplish the more comprehensive procedure being performed and that it may not be billed.- Therefore, the new edit makes sense but probably won't be used too frequently.
 
Medicare Will Bundle Wound VAC Codes

Active wound care management codes 97602-97606 officially became components of 556 different codes on April 1, including fracture care, amputation and debridement codes.

Orthopedic coders report that carriers are already denying claims for negative-pressure wound therapy codes 97605-97606 along with debridements billed with 11010-11012, but you can use a modifier to separate these bundles if you perform the wound VAC treatment as a distinct procedural service.