Orthopedic Coding Alert

Don't panic when your surgeon encounters unforeseen complications during surgery

Orthopedic surgery coding can sometimes hold surprises. For example, suppose your surgeon plans to perform a TKR and hardware removal, but he ends up performing what he refers to as a -custom- knee replacement with nonunion repair. You can overcome this challenge with a thorough review of the op note and careful use of modifiers.

Consider the following operative report, submitted to Orthopedic Coding Alert by Debi Scarfo, biller at Bannon Orthopaedics and Sports Medicine in Queensbury, N.Y. After you review the op report, code the procedure before you check out our expert advice below.

Preoperative diagnosis: Status post severe bicondylar proximal tibia fracture, and post open reduction internal fixation with bone grafting (failed).

Procedure overview: The surgeon scheduled a patient for hardware removal (from a tibia fracture), as well as a total knee replacement. When he opened the patient, he found it necessary to perform major deep hardware removal, tibial tubercle reconstruction, trabecular metal coil insertion, wedge medial tibial base plate, and long stem tibial component (total knee replacement).

Op Note: Trace the Surgeon's Work

The pertinent details of the op report follow: After I opened the patient, I noted an obvious nonunion of the tibial tubercle. I removed the tibial tubercle wires and removed the plates and found that the massive amount of bone grafts that we had used intraoperatively had not consolidated and there was a tremendous amount of necrotic bone. I ununited the medial tibial plateau and discarded the large (3-cm) piece.

I used a trabecular bone proximal tibial reinforcer and shaped the inner tibia, removing some of the remaining cancellous bone from the proximal tibia to incorporate the trabecular cone into the proximal tibia.

We placed a rod up through the femur, inserted the distal femoral cutting block jig, cut the distal femur, and measured the femur to a size F. We cut the anterior-posterior femurs and chamfered them. We removed medial and lateral meniscal remnants and the anterior-posterior cruciates.

We again debrided the proximal tibia and found that the anteromedial tibia was deficient for 5 or 6 cm. With the rod in place down through the tibia, we cut the proximal tibia at about 1 cm. We reamed the tibial canal to 13 mm for the rod and left the rod in place.

We shaped the inside of the proximal tibia to accept a cone, and then set the distal portion of the cone medially on the tibia and inserted it inside of the proximal tibial metaphysis. We settled on a #17 polyethylene that allowed us to full extend and flex with stability medially and laterally in both flexion and extension.

We then addressed the tubercle nonunion. We drilled two holes in the trabecular metal and passed two wires through the holes and back out. We weaved the wires through two holes in the tibial tubercle, affixing the tubercle to the anterior tibia and trabecular metal.

We drilled another hole distally in the anterior tibia for another wire, and then inserted cement in a press-fit fashion on to the tibial surface with a cone and long-stemmed tibial component in place. The femur, tibia and femoral components fit nicely with the 17-mm insert, and we used a posterior cruciate replacement-type prosthesis. After the tibial side cement cured, we cemented on the femur and the patellar button (a 26 mm). Then we reattached the tibial tubercle. I took some bone from the femur (an autograft) and packed it in around the tubercle.

Coding Advice: Follow 3 Steps

Step 1: Report the Knee Replacement. Although the surgeon discussed the tibial nonunion first, you should code the total knee arthroplasty first. Not only is this the higher-paying procedure, but it was also a complicated surgery and the main intent of the surgeon's visit to the OR with the patient.

You should report 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee arthroplasty]) for the knee replacement.

Step 2: Address the -Custom- Nature of the Procedure. The surgeon didn't perform a standard knee replacement, because the surgery was vastly complicated by the fracture nonunion and the amount of necrotic bone. Therefore, you should append modifier 22 (Unusual procedural services) to 27447, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.

When you append modifier 22 to a CPT code, you-re telling the payer that you went over and above what the code describes, and therefore, you deserve additional reimbursement. Ask your surgeon to determine how much additional time or effort he spent on the knee replacement.

Example: If the surgeon tells you that he went 20 percent over the normal work required for a knee replacement, you should request 20 percent more reimbursement than 27447 normally pays. At 39.88 RVUs, you should expect about $1,511 when you report 27447. If the surgeon performs 20 percent additional work, you-d bill 27447-22 and request $1,813 instead of the standard $1,511.

When you submit your claim with modifier 22 appended, remember to send a letter from the surgeon in which he describes the unusual nature of the surgery, along with the op note.

Step 3: Treat the Nonunion. To collect reimbursement for the tibial nonunion repair with autograft, you should report 27724-51 (Repair of nonunion or malunion, tibia; with iliac or other autograft [includes obtaining graft]; Multiple procedures).

Because the National Correct Coding Initiative (NCCI) does not bundle 27724 into 27447, you don't need to append any additional modifiers to the procedures.

You should not separately report the hardware removal (20680). Not only does the NCCI bundle this code into 27447, but the AMA's position is that if you need to remove hardware to necessitate a more comprehensive procedure, then you should not separately report the hardware removal.