Orthopedic Coding Alert

Orthopedic surgeons often tackle two procedures in tandem. Intervention to correct one condition sometimes reveals a second one. Correcting the second condition during the same operating room session is good for the patient. The challenge for the coder is to determine whether the multiple interventions are bundled and then code appropriately.

A 45-year-old male who fell from a ladder at work had arthroscopic surgery for attempted reduction and internal fixation of a fracture of the right wrist. Standard 3.4 and 6.0 portals were used to accomplish arthroscopic exposure of the wrist.

The fracture hematoma was removed. It was then possible to demonstrate evidence of a displaced articular surface involving the wrist. Pins were used (interfocal technique) to obtain a reduction to what was thought to be an acceptable level of displacement (less than 1 mm.). Stability during minimal range of motion involving the wrist was confirmed radiographically with the Xiscan.

Examination of the ulnar aspect of the wrist revealed evidence of a tear in the triangular fibrocartilage complex (TFCC), type I. The tear was excised by debridement to a stable-appearing remnant by using straight and angle baskets.

There are unique CPT codes for each procedure in this case. And the distinction between 29847 (arthroscopy, wrist, surgical; internal fixation for fracture or instability) and 29846 (arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement) suggests both can be used.

One provider tried to do just that, assuming the two procedures could be considered multiple surgeries. Because the Medicare Unbundling Guidebook (for determination of included and non-included services) lists the procedures as separate and distinct, the provider felt secure in coding them separately.

But the payer considered 29846 part of a global procedure under 29847, and would not reimburse for any portion of it.

Code Separately or Bundled?

Two things happened during the surgery in this case example. But how are they related to each other? That is the question the Health Care Financing Administration (HCFA) wants coders to ask and answer.

Medicares New Correct Coding Combinations and HCFAs Common Procedure Coding System are used by most payers to determine how multiple interventions during the same session will be paid.

And Medicare guidelines (Chapter 22, Global Surgery & Related Issues) emphasize that multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries or components of surgeries will not be separately reimbursed.

The arthroscopic and excision procedures in the case outlined have separate codes. They represent multiple surgeries. Following Medicare/HCFA guidelines, the procedure with the highest relative value units (RVU) should be paid first, and at 100 percent. The second procedure should be paid at 50 percent. [...]