Orthopedic Coding Alert

With football season in full swing, your orthopedic surgeon will probably treat some weekend warrior injuries -- especially for anterior cruciate ligament (ACL) damage. Learn the difference between revision and reconstruction -- and what services you might be able to report separately -- to score your best coding every time.

When your physician treats an ACL injury, he has two options: repair the ligament, or reconstruct it. The CPT code for either procedure is 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction).

"A repair is rarely performed -- a reconstruction is almost always needed," says Shelly Ghrist, CPC, assistant manager of Wolf Creek Medical Associates in Grove City, Penn. "If the injury isn't severe enough for a reconstruction, conservative methods -- such as rest, ice, and elevation -- are typically preferred."

Caution: Debridement of torn fibers does not equal ACL reconstruction or repair. If your physician focuses on debridement, report 29876 (Arthroscopy, knee, surgical; synovectomy, major, two or more compartments [e.g., medial or lateral]) or 29999 (Unlisted procedure, arthroscopy) instead.

ACL procedures can be more complex than what 29888 describes. For example, your surgeon may have to remove the hardware that another surgeon left in place, take out a previously placed tendon graft, and revise tibial and/or femoral tunnels. Scar tissue also might make surgical dissection more complicated. Keep these things in mind when coding more involved cases:

• If your surgeon documents spending extra time on the case, you might be able to append modifier 22 (Increased procedural services). "The use of modifier 22 would only be appropriate if there was extensive scarring or documented increased complexity," points out Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, coding and compliance supervisor for Proliance Orthopedics and Sports Medicine in Belleview, Wash.

"This is not commonly the case for a primary repair and is more appropriate in revision ACL procedures."

• Indicate any extra time revision surgery involves compared to standard ACL reconstruction. An ACL repair often takes about an hour to one hour and 15 minutes to complete, Stumpf says. "A revision procedure can add 20 to 30 minutes, depending on the findings," she adds.

• Some payers might prefer 29999 (Unlisted procedure, arthroscopy) for more complicated ACL cases. Use 29888 as the base code and increase your request for reimbursement based upon the documentation. For example, if your surgeon states, "50 percent increased complexity," your reimbursement request would be for 50 percent more than reimbursement for 29888 (depending on the surgeon's documentation).

Revision red flag: Your orthopedist might sometimes remove metal hardware before he can proceed with  another procedure. Don't automatically submit a code such as 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]), however, because CPT guidelines prohibit reporting 29888 with a hardware removal code.

"A revision ACL procedure can be reported using 29888-22 or 29999," Stumpf says. "This is carrier specific and practice specific." Explain why the procedure was more complex and how the revision differed from the initial repair or reconstruction.

"Be careful to report V54.01 (Encounter for removal of internal fixation device) or 996.49 (Other mechanical complication of other internal orthopedic device, implant, and graft) to the diagnosis code for the procedure to support the presence and removal of prior hardware," Stumpf adds. "Also code any bony deficit (731.3, Major osseous defects), adhesions (718.56, Ankylosis of joint; lower leg), or other anatomical changes that lead to increased complexity and support your claim for increased reimbursement."

Although the ACL global package is fairly comprehensive, you can sometimes report knee arthroscopy codes 29874 and 29877-29883 in addition to the ACL procedure, according to the AAOS.

For starters, follow these three tips:

• Watch locations. AMA guidelines state that the physician must perform chondroplasty or loose body removal in a different knee compartment before you can report separate codes.

• Verify if the patient is non-Medicare. The AAOS Global Service Data (GSD) book indicates that you need special documentation before reporting 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body [e.g., osteochrondritis dissecans fragmentation, chondral fragmentation]). "They're looking for documentation that the arthroscopy is not in any way related to the ACL repair," Ghrist explains. "This would require you to send operative notes with the claim."

• Double-check coding edits. The Correct Coding Initiative (CCI) bundles 29874 and 29877 (... debridement/ shaving of articular cartilage [chondroplasty]) into 29888. Translation: Expect these bundles if your payer requires you to apply CCI guidelines to your claims.

Arthroscopy example: Your orthopedist performs an arthroscopic-aided ACL repair and performs medial meniscus repair and partial lateral meniscectomy. Taking the previous tips into consideration, you should report:

• 29888 for the ACL repair

• 29882-51 (... with meniscus repair [medial OR lateral]; Multiple procedures) for the medial meniscus repair

• 29881 (... with meniscectomy [medial OR lateral, including any meniscal shaving]) for the partial lateral meniscectomy.

Remember, report modifier 51 only to those payers who accept it. And if the payer requires you to follow CCI guidelines, append modifier 59 (Distinct procedural service) to override the mutually exclusive edit for 29881 and 29882. When deciding which code to append modifier 59 to, follow your payer's preference.