Orthopedic Coding Alert

Increasingly common bilateral total knee replacement (TKR) surgeries 27447 (arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee replacement]) present coding and reimbursement challenges. Payers reject claims for both surgeries done simultaneously by different surgeons and question the need for both to be done at once. As Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates, an 11-physician orthopedic specialty group practice in New Brunswick, N.J., explains, orthopedic coders are no strangers to claim rejections for bilateral TKRs. Im sure our office is not unique in getting frequent denials because carriers disregard modifiers and deny one of the two procedures as a duplicate, says Stout. The issue is especially confusing given that there are several correct ways of reporting bilateral procedures, depending upon the carriers specifications.

Reasons to Go Bilateral

A bilateral TKR that takes place in one, rather than two, operative session is called a simultaneous bilateral TKR, as opposed to a staged bilateral procedure in which one of the patients knees is replaced during one surgery and the other during a second surgery at a later date.

Patients who require one TKR, often need two because as one knee has deteriorated, they have favored the other and damaged it as well. Proponents of bilateral TKRs extol the benefits from both a patient well-being and a financial perspective. Patients who are good candidates for the bilateral procedure often have a faster recovery because they undergo one rather than two rehabilitation phases. Cost savings include fees for operating room space, x-rays, physical therapy, anesthesia and lab tests. Although the simultaneous TKRs are not for everyone, particularly patients who have a history of heart problems or blood clotting, for younger, healthier patients they often represent a fast track to full recovery.

More Than One Right Way to Code and Submit

Many coders initial reaction is to code the surgery using the -62 modifier (two surgeons). But some carriers may reject this modifier because it often implies that the two surgeons are of different specialties. According to CPT, the -62 modifier is used when two surgeons operate together as primary surgeons performing distinct parts of a single reportable procedure, says Stout. Its use implies that both surgeons expertise was needed to handle different aspects of the same complicated procedure, rather than conduct two unrelated surgeries simultaneously.

A typical example of this is when an orthopedic spine surgeon and a vascular surgeon work together on an anterior lumbar fusion (22808-22812). For this reason, when two surgeons perform simultaneous bilateral TKRs, it is not co-surgery in the strictest sense of the word; it is two independent surgeries that happen to be taking place on the same person at the same time. But Stout acknowledges that some carriers will want to see the -62 modifier appended to claims for bilateral TKR. If youre dealing with Medicare, you will have to use the -62 modifier since Medicare has included simultaneous bilateral TKRs in their definition of what constitutes co-surgery. Certainly, this is not the wrong way to code. But for some commercial carriers, it may not make as much sense as some other coding options, says Stout.

Anita Foster, MA, CPC, CCS-P, vice president of The Coding Network, a coding consulting firm based in Beverly Hills, Calif., thinks that -62 may be the best way to get the claim paid. Some carriers, including Medicare, are going to look at a bilateral TKR as a co-surgery, even if it isnt co-surgery in the most literal sense, she says, because Medicare requires that the claim for such a procedure appear on the same line of the HCFA 1500 form, with each surgeon coding as the primary surgeon. The coding sequence would read 27447-62-50, 27447-62-50. The -50 modifier is added to indicate a bilateral procedure. By appending the -62 modifier, each surgeon generally can expect to be paid for 62.5 percent of the fee for one procedure.

Stout prefers, whenever possible, to submit two separate claim forms for the two surgeons, using 27447 with either the -LT or the -RT to indicate left side or right side. This emphasizes to the payer that two separate surgeries took place at the same setting. Plus, the separate claims go through two different claims adjusters, and there is less confusion. One is approving payment for the left side, the other for the right, she says. Although the potential still exists for reductions of up to 50 percent for the second surgery, If your carrier will let the claim go through this way, there is the potential for greater reimbursement, Stout adds.

When using the -LT and -RT modifiers, do not append the -62 as well. The -62 tips off the carrier that they should expect to see another claim for the other surgeon, says Stout. And this is my problem with the -62. The bilateral TKR is two separate surgeries and should reimburse better than 125 percent for both.

Handling Global Care

Assuming that the two surgeons are from the same practice, divvying up the fees for global care becomes an internal accounting matter. But when the two surgeons are from different practices, a letter should be sent along with the claim outlining which physician is responsible for the preoperative and postoperative aspects of global care for 27447. The letter should explain the role of each doctor, says Stout. Assuming that the physician whose patient is being operated on will do the pre- and postoperative care, the carrier should split reimbursement based on who is doing what portion of the surgery. For two physicians within the same group practice, it might not be necessary to spell out these divisions of care, but for different practices, each physicians claim and operative report should give the percentage of the global care for which they are responsible.

Make Your Case

Before submitting billing for bilateral TKRs, determine how the individual carrier wants the surgery reported. Contact your highest-volume carriers and find out their requirements for documentation. Regardless of the method used to submit the claim, coders should not anticipate receiving more than 150 percent reimbursement for the two surgeries. Because simultaneous bilateral TKRs are becoming more frequent, carriers should be easing their close scrutiny of claims for two 27447s.

Hopefully, says Stout, carriers will realize the savings in doing simultaneous TKRs and make these claims easier to collect.