Orthopedic Coding Alert

Question: I reported mosaicplasty with code 0012T (Arthroscopy, knee ...), but Cigna denied it because the service "has not been shown in the literature to have improved outcomes as compared to standard treatments." Because the surgery did not require preauthorization, I had no way of knowing it would be denied. Should I have reported an unlisted-procedure code instead?

New Hampshire Subscriber Answer: Unfortunately, not all insurers cover the Category III codes because this code set represents emerging technologies. This does not mean that you should report an unlisted-procedure code instead to avoid a claim denial. Code correctly, even if it means that you'll have to collect payment from the patient instead of the insurer. To avoid such denials in the future, you should always preauthorize any services to which CPT assigns a Category III code.
 
Some insurers publish policies outlining coverage criteria for these procedures on their Web sites, which can help you authorize the procedure quickly. Aetna, for instance, indicates in Coverage Policy Bulletin 364 that it covers mosaicplasty for nonrepairable stage-three or -four osteochondritis dissecans, as well as several other diagnoses.