Orthopedic Coding Alert

Question: Our insurer requested documentation when we billed 29876 (Arthroscopy, knee, surgical; synovecto-my, major, two or more compartments [e.g., medial or lateral]). A few weeks later, it sent us a check for 29875 (... synovectomy, limited [e.g., plica or shelf resection] [separate procedure]). Our orthopedist thinks we should accept the payers response and the fact that they downcoded our claim. I dont want payers to think that we intentionally upcode. Should we appeal?

Pennsylvania Subscriber

Answer: You should definitely respond to the insurer. You can never be too concerned about regulatory exposure directed at your practice, and failure to respond may appear as an admission that you upcoded your limited synovectomy claim.

Review your documentation to ensure that it reflects the two (or more) compartments that the surgeon addressed during the surgery. Chances are your carrier randomly selected 29876 claims for review, and your documentation did not support using the code.

If you feel that your documentation supported the major synovectomy claim, send the insurer a letter with another copy of your documentation, circling the references to multiple compartments. Based on this letter, the insurer may revise its original position and pay you the difference between 29875 and 29876 (about $125), or it may respond with a more detailed explanation of why it downcoded the original claim.