Orthopedic Coding Alert

CMS adds arthroscopic knee lateral release to endoscopic knee group

Thanks to a new Medicare transmittal, you could be looking at about a $150 pay cut when you perform arthroscopic knee lateral releases (29873) with other knee procedures in the endoscopic base family of 29870.

How is that possible? CMS recently changed the way practices should report 29873 (Arthroscopy, knee, surgical; with lateral release).

Old way: In the past, if your practice reported 29873 with another arthroscopic knee procedure, such as 29880 (...with meniscectomy [medial AND lateral, including any meniscal shaving]), Medicare payers subjected the lower-valued procedure to the "multiple-procedure rule." Medicare paid the first procedure at the full relative value unit (RVU) allowable rate but discounted the second procedure by 50 percent.

New way: Now, however, if you report 29873 with any other code in the 29870-29887 range, you'll be subjected to Medicare's multiple-endoscopic-procedure rule, not the multiple-procedure rule.

Multiple-Procedure Rule No Longer Applies

Medicare Transmittal 558, which carries an effective date of Jan. 1, 2005, and an implementation date of July 5, instructs carriers to change 29873's multiple-procedure indicator from a "2" (which meant that standard multiple- procedure rules applied) to a "3," which means that special rules for multiple endoscopic procedures apply if you bill the procedure with another endoscopy in the
same family. 

Multiple-Procedure Rule Paid More

Multiple endoscopic rule basics: The Medicare Carriers Manual 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."

The base code in the knee family (29870) carries 10.78 RVUs (not including geographic adjustments). Therefore, if you bill 29873 with 29883 (Arthroscopy, knee, surgical; with meniscus repair [medial AND lateral]), your Medicare carrier will reimburse you using the full RVU allocation for 29883 (21.98 RVUs, or about $833).

The payer will then pay you just 2.81 RVUs for 29873. The insurer would calculate this figure by subtracting 29870's 10.78 RVUs from 29873's 13.59 RVUs. Medicare carriers then multiply the RVUs by the conversion factor of 37.8975 to come up with the procedure's value, which would total about $106:

13.59 RVUs for 29873 - 10.78 RVUs for 29870 = 2.81
2.81 x conversion factor of 37.8975 = $106.

Using the previous payment rules, you would have collected the full $833 for 29883, and about $257 for 29873 (50 percent of the $515 allotted for 29873). Therefore, you'll now be about $150 short if you report 29873 with other codes in the 29870 base family.

It's not endoscopy, but the rules apply: "Coders may wonder why the multiple-endoscopy rule applies to arthroscopies," says Angela Daniels, RN, office manager for Thomas Daniels, MD, in Seattle. "You just have to keep an eye on the 'arthroscopic base code' column in the Fee Schedule to see whether your arthroscopies fall under one of the base codes. If they do, then you have to follow the multiple-endoscopy rule. Don't bother arguing that you performed an arthroscopy and not an endoscopy."

Note: For information on other orthopedic-specific endoscopic base code families, see our chart, "Meet the Families: Check out the Endoscopic Base Codes for Orthopedists" later in this issue.

CMS Changes Bilateral, Mult. Procedure Indicators
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News for bilateral claims: The new CMS transmittal also instructs carriers to change the bilateral indicator for code 20690 (Application of a uniplane [pins or wires in one plane], unilateral, external fixation system) from "0" to "1."

The "0" indicator meant that in the past you could not use modifier -50 (Bilateral procedure) with 20690, but the "1" indicator means that you can now append modifier -50 to your external fixator claims and collect 150 percent of the assigned fee schedule amount.

"Most carriers allowed practices to bill 20690 claims with the -LT (Left side) and -RT (Right side) modifiers in the past," says Jay Neal, an independent coding consultant in Atlanta. "After all, the descriptor refers to 'unilateral,' so it was clear that you could bill this code once for each side."

Therefore, using the old payment rules, payers subjected the second side to the multiple-procedure rule and paid orthopedists 100 percent for the first side and 50 percent for the second. "So reimbursement shouldn't change for this service," Neal says. "It just maybe makes coding a little more tidy because you can bill the whole thing on one line now," rather than reporting two separate line items.

Good news: In the past, Medicare payers assigned a "2" multiple-procedure indicator to 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]), which meant that the standard multiple-procedure rules applied (carriers paid the first procedure at 100 percent and the second at 50 percent). But this rule vexed many orthopedic coders, Daniels says, because 20926 is modifier -51 exempt, according to CPT.

CMS tidies up that dichotomy and now assigns a "0" multiple-procedure indicator to 20926, which means that Medicare payers will not make any payment adjustments and will pay 20926 at 100 percent, even if the orthopedist performs the procedure with another service.

"In reality, this sort of jibes with the way Medicare was always paying the procedure. But coders will no longer scratch their heads when they see the Fee Schedule," Daniels says.

To read the full Medicare transmittal, visit the CMS Web site at www.cms.hhs.gov/manuals/pm_trans/R558CP.pdf.

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Correction:
Look for 29873, 29883 Payment Combination Issues

Our July article "Expect a Pay Cut When You Report 29873 With Other Surgeries" included a typographical error. Under the subheading "Multiple Procedure Rule Paid More," we noted that "If you bill 29873 with 29882 (Arthroscopy, knee, surgical; with meniscus repair [medial OR lateral]), your Medicare carrier will reimburse you using the full RVU allocation for 29883 (21.98 RVUs, or about $833)."

It should have said that if you bill 29873 with 29883 (Arthroscopy, knee, surgical; with meniscus repair [medial AND lateral]), the Medicare carrier will reimburse you using the full RVU allocation for 29883.

We have bolded the new content above, and we have made the correction on our online subscriber system at www.codinginstitute.com.

Thanks to Robert W. Westergan, MD, medical director at Jewett Orthopaedic Clinic in Winter Park, Fla., for catching the error.