Overcome Reimbursement Challenges With Bilateral TKRs
Published on Sun Oct 01, 2000
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 [...]
