Orthopedic Coding Alert

CPT 2008 brought you 27416, an all-new mosaicplasty code. That makes now the perfect time to study up on how to choose between osteochondral graft codes 27415, 27416, 29866 and 29867. Use these strategies, and you-re sure to choose the right code every time.

Before the 2008 arrival of 27416 (Osteochondral autograft[s], knee, open [e.g., mosaicplasty] [includes harvesting of autograft(s)]), CPT didn't offer a code for this open osteochondral autograft procedure, says Kathleen Nelson, CPC, professional coder for the orthopedics department at Fletcher Allen Health Care in Burlington, Vt.

Instead, guidelines instructed coders to use 27599 (Unlisted procedure, femur or knee), Nelson says. She would also add a procedure descriptor and send it with the operative report to the insurance companies.

Having a dedicated code for this procedure and not having to rely on an unlisted-procedure code is exciting, Nelson says. "We all know how difficult it is to get reimbursement on an unlisted code."

But to be sure you-re using this new code correctly -- and distinguish it from similar codes -- you need to know whether the procedure is open or arthroscopic and whether the surgeon uses an autograft or allograft. Note how these elements apply to these descriptors:

- 27415 -- Osteochondral allograft, knee, open

- 27416 -- Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s])

- 29866 -- Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s])

- 29867 -- Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty).

This chart displays another way to look at it:

Before you can choose the proper osteochondral graft code, you have to decide whether the surgeon used an autograft or allograft.

Autograft: An autograft refers to a graft the surgeon takes from the patient, Nelson says.

The surgeon should document where he harvested the graft from to help you determine that he used an autograft, Nelson says. If you don't see this documentation, check with the surgeon to be sure you-re choosing the proper code, she says.

Tip: The surgeon often takes the autograft from a non-weight-bearing portion of the same knee.

Codes 27416 and 29866 specify autograft in their descriptors. Note that both code descriptors state, "includes harvesting of autograft(s)," which means that you should not report a separate graft code, Nelson says.

Allograft: An allograft comes from a donor other than the patient, most likely from a bone or tissue bank, Nelson says.

The surgeon should document "allograft" and perhaps explain why an autograft was not sufficient, Nelson adds.

Codes 27415 and 29867 specify the term "allograft" in their descriptors.

Arthroscopic: You should only report 29866 and 29867 when the surgeon performs an arthroscopic procedure, which is minimally invasive and involves the surgeon inserting an arthroscope -- a type of endoscope -- into the joint through a small incision.

You may see documentation such as "The standard anterior medial and anterior lateral arthroscopic portals were created, and we commenced the arthroscopy," says Leslie Follebout, CPC-ORTHO, coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md.

Open: Reserve codes 27415 and 27416 for open procedures, which require the surgeon to cut skin and tissue so he has direct access to the joint involved.

Documentation should indicate this incision and direct access. For example, "Because I needed to visualize the intra-articular portion of the knee, I incised through the synovium and exposed the patella," Follebout says.

Once you-ve chosen the proper graft code, you may be tempted to add other codes to your claim. The AMA's

CPT 2008: Professional Edition offers many exclusionary notes to prevent you from pairing codes payers don't want to see together.

Smart move: Even with access to multiple coding software programs, Follebout still reads the CPT guidelines for these codes every time she gets a report for one of these procedures.

Here are the notes:

- 27415: Don't report with 27416.

- 27416: When performed at the same session, don't report with 27415, 29870, 29871, 29875, 29884. And when performed in the same compartment, don't report with 29874, 29877, 29879, 29885-29887.

- 29866: When performed at the same session, don't report with 29870, 29871, 29875, 29884. And when performed in the same compartment, don't report with 29874, 29877, 29879, 29885-29887.

- 29867: When performed at the same session, don't report with 27570, 29870, 29871, 29875, 29884. And when performed in the same compartment, don't report with 29874, 29877, 29879, 29885-29887.

In addition to not reporting codes together inappropriately, keep a close eye on your units.

Code 27416's descriptor refers to "autograft(s)," which means you should report the code "only one time for the osteochondral repair, regardless of the number of grafts or harvests required to complete the repair," according to CPT Assistant, January 2008, says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, president of Healthcare Consulting and Coding Education in Boardman, Ohio.

The same holds true for 29866.

Unfortunately, some payers consider osteochondral graft procedures experimental. Best bet: Precertify the surgery, and verify the patient's benefits before scheduling it so the patient knows whether the payer will cover the procedure. Payer policies may list the precise circumstances that they consider medically necessary, so you know which patients are eligible.

Example: You can find Aetna's policy online at http://www.aetna.com/cpb/medical/data/600_699/0637.html, Follebout says.

Aetna's policy, which is fairly representative of private payers, states that it considers autologous osteochondral mosaicplasty and osteoarticular transfer system (OATS) experimental and investigational. But it also states, "Aetna considers osteochondral autografts medically necessary for repair of small (less than or equal to 1 cm²) focal chondral defects of articulating cartilage that are causing significant symptoms that have not been relieved by appropriate nonsurgical therapies."