Orthopedic Coding Alert

Dont miss reporting blood platelets placement in this situation.

If your orthopedist is performing platelet rich plasma (PRP) injections with surgical reconstructions and youre looking for a way to report this, you may be making your life more difficult than it should be. Most likely, you should consider this inherent to the surgical procedure.

Thats not what most coders and physicians want to hear. This is currently a great challenge for our physicians who are performing this procedure with excellent outcomes -- yet they are being told they should not be paid for it, laments Gloria Caballero, director of finance at OED Orthopaedics in Warrenville, Ill.

But take heart: In one situation, you might be able to get away with an unlisted procedure code to reflect the additional work.

To minimize denials and save precious time, discover what PRP involves, what you should report, and what codes you should avoid.

What Is PRP?

In the past seven years, PRP has taken off in orthopedic medicine. These treatments focus on healing joints: ligaments, tendons, and cartilage. A primary problem is that there is little blood flow in the joint tissues compared with muscle tissues. PRP stimulates blood flow to the area which allows for the breakdown of unhealthy tissue and the creation of new, healthy tissue. Patients heal faster.

Benefit: The primary advantage of PRP is that the orthopedist places blood platelets involved in healing damaged connective tissue into the area -- rather than wait for the body to do so on its own. By using ones own blood platelets, which the body quickly replaces, rejection is not an issue.

PRP addresses surgical healing and tendonitis, says Connie Treonze, practice administrator for Associated Orthopedics in Union, N.J.

Our hand surgeons primarily do this procedure as a treatment for epicondylitis, Caballero adds.

The problem is there is no code at this point that really fits what the physician performs, Caballero says.

Heres What to Do on Your Claim

Example 1: The patient undergoes an orthopedic surgery. The orthopedic surgeon draws 60 cc of the patients blood, which is then centrifuged for 15 minutes to separate PRP from the platelet-poor plasma. The surgeon injects the PRP into the operative site.

Although you might want to reflect the surgeons work with a code, you should consider the platelet instillation into the surgical site as part of the surgery. In other words, you should not code for this, says Lori Pierson, BS, RHIA, CPC, coding specialist for Promedica Physician Group in Sylvania, Ohio.

You can find this advice in CPT Assistant November 2005, CPT Assistant March 2009, and ICD-9 Coding Clinic, Vol. 19, No. 2, 2nd Qtr 2002. The CPT advisors representing the College of American Pathologists and the American Society for Clinical Pathology second this instruction.

Example 2: Suppose, however, the orthopedist is performing this procedure for epicondylitis, and it is the only procedure he performs.

You should report the appropriate injection code (such as 20551, Injection[s]; single tendon origin/insertion). If the surgeon does the blood draw and platelet processing, you can report 86999 (Unlisted transfusion medicine procedure).

Cross These Codes Off Your List

Watch out: If vendors are advising you to use a slew of CPT codes, be wary. I know there is a great controversy regarding the proper coding methodology for these procedures, and vendors may not always provide appropriate advice, Caballero says. Its up to practice coders to determine what to code and what not to.

For instance, you should not report 36513 (Therapeutic apheresis; for platelets) because the surgeon did not perform therapeutic apheresis. Also, cross out 86985 (Splitting of blood or blood products, each unit) as an option for describing the derivation of the platelets.

Therefore, you shouldnt report 86940 (Hemolysins and agglutinins; auto, screen, each) either.

Do not rely upon 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]), because blood is not a paratendon, fat, dermis, or tissue graft.

You should also avoid codes 20552 (Injection[s]; single or multiple trigger points[s], 1 or 2 muscle[s]), 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), 36514 (Therapeutic apheresis; for plasma pheresis), or 38230 (Bone marrow harvesting for transplantation). They do not describe a PRP injection from the patients blood, drawn and centrifuged, and injected back into the involved anatomic site.

Still unsure? Refer to your payers guidelines, as they can offer recommendations as to what you shouldnt report. For example, First Coast Surgical Options, a Medicare carrier for Florida and Connecticut, addressed this pitfall in their Medicare Part B January 2007 update about Vitagel, another hemostasis product:

Recently, providers may have received instructions that may result in the incorrect billing of VITAGEL  Surgical Hemostate using CPT code 20926. Hemostasis is considered to be an integral part of any surgical procedure. Therefore, VITAGEL Surgical Hemostat is not separately payable by the carrier and should not be billed using CPT code 20926.