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.

Note: The 50 percent allowance applies for the second through the fifth highest-valued procedures, which should be submitted in that order.

Excision of TFCC tear is part of a global procedure (29847) for the arthroscopic surgery on the right wrist. The payer will only reimburse for this procedure because the payer considers the excision incidental to or a component of the primary procedure, arthroscopic surgery.

To which highest value do the guidelines refer? Is it the highest relative value or the highest value assigned to a procedure billed by a provider?

In this case, the provider argued that if the payer would only reimburse for one procedure as the global procedure, it should reimburse for the one that had the higher relative value. In the case of this payer, it was the excision of the TFCC. But when the claim was submitted, the provider assigned a higher value (billed amount) to the 29847 procedure, and that is the higher value the payer used, even though the reimbursement for it was less than for 29846.

Procedure    Provider Value ($)    Reimbursement Value ($)
29846		4,332			3,060
29847		5,200			2,502

	

When the provider challenged the payer, the payer wrote, Our policy is to consider the higher charge the primary procedure, which was paid. Therefore, the 29846 becomes part of the global package and is not considered separate.

The providers argument that higher value should apply to reimbursement value did not sway the payer.

Modifier Solutions

Using the -59 modifier (distinct procedural service) or the -51 modifier (multiple procedures) on the claim and including a short and simple explanation of how the procedures are distinct (or multiple) might get the payer to consider reimbursing under the 50 percent cascade scheme, instead of under the global.

For example, New Correct Coding Combinations from Medicare advises if debridement is necessary to associated trauma, the codes describing debridement are separately payable. (They are not payable if debridement is strictly due to the fracture.)

If the provider can make a case for necessary to associated trauma, use a -59 modifier to describe the situation. But then proceed with tempered optimism.

Why? A modifier only works if the payer recognizes the modifier, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator who was recently named the American Association of Professional Coders coder of the year. In this case, the payer looked at the operative report (in several iterations with the provider) and still rejected the payers second claim. The modifier would not have helped.

There is one other possibility. Know the payer and the reimbursement level, says Callaway-Stradley.

Then list the highest-paying (not the providers highest charge) first when billing for multiple procedures that might be construed as components of one another. In other words, define the major procedure as the highest-paying procedure when the complexity of either procedure done separately is arguably the same, and when one pays more than the other.

The first procedure on the list, the major procedure, has the best chance of getting reimbursed. As long as the procedure has been done and the operative report backs you up, you can decide in which order to list the procedures, says Callaway-Stradley.

Improving Operative Reports

Wrist fractures, particularly distal radial fractures, are common injuries among the elderly (falls) and the young (high-energy trauma). Treatment aims to restore maximum function, maintain strength and thwart the development of post-traumatic arthritis.

Distal radial fractures are so commonabout 15 percent of all fracturessome surgeons do not name them, but simply refer to wrist fracture. Consequently, some operative reports are not as specific as they should be about which bones are the focus of the OR session.

Although a surgeon certainly knows which bone is affected when he writes, arthroscopic inspection of the wrist fracture, the payer will want to know which bone (i.e., radius, ulna) and which part of the bone.

Working with physicians to improve the clarity and thoroughness of operative reports is another way to ensure proper reimbursement.

If All Else Fails

If the scenario is typical of the problems a provider is having with a payer, Callaway-Stradley says, It might be time to consider whether continuing a contract with the payer is beneficial to the practice. Decide whether the company is being fair to you.

Callaway-Stradley explains a continued association with the payer might bring in enough clients to offset the occasional odd reimbursement. If so, continue. But if the odd (and low) reimbursement scheme of the payer is representative of their policies, it might be time to sever ties at the earliest opportunity.