Orthopedic Coding Alert

Do you know which injury is more common: ACL or PCL tear?

Patients reporting to the orthopedist with torn anterior cruciate ligaments (ACLs) or posterior cruciate ligaments (PCLs) will likely be receiving several services from your practice. When it comes time to code these encounters, will you be ready?

Being ready means knowing how to report the initial encounter all the way through to the surgery.

Check out this expert advice on nailing ACL/PCL tear repair coding every time.

Start With E/M for Diagnostics

The surgeon will first need to diagnose an ACL/PCL tear before they can repair it. The diagnosis process will likely start with an office/outpatient evaluation and management (E/M) service, which you’d report with a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set.

During this E/M, the surgeon will likely perform one of two tests. The first test is “the Lachman’s test, taking the knee through a specific range of motion to pain level tolerated,” explains Misty Smith, CPC, COSC, at Bluegrass Orthopaedics in Georgetown, Kentucky. This test is to gauge a suspected ACL tear.

There is a similar test for a suspected PCL tear called a drawer test, explains Drew Warnick, pediatric orthopaedic surgeon at Children’s Orthopaedic and Scoliosis Surgery Associates, LLP.

X-Rays, MRI Confirm/Deny Diagnosis

After the E/M, the surgeon will likely perform X-rays to rule out fracture, Smith confirms.

And finally, the surgeon will likely perform a magnetic resonance imaging (MRI), which should confirm or deny the presence of an ACL/PCL tear, Warnick says.

These are the codes you’ll choose from when reporting X-rays and MRIs related to ACL/PCL tears:

X-ray: 73560 (Radiologic examination, knee; 1 or 2 views) through 73565 (…both knees, standing, anteroposterior)

MRI: 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) through 73723 (… without contrast material(s), followed by contrast material(s) and further sequences)

Modifier alert: Don’t forget modifiers LT (Left side) and RT (Right side) to indicate the laterality of the X-ray/MRI. You’ll also need LT/RT when reporting ACL/PCL surgeries.

Use These CPT^® Codes on ACL/PCL Tear

The surgical codes you’ll report for ACL/PCL repair are 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) and 29889 (Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction). An ACL tear is far more common than a PCL tear, so be ready to use 29888 more than 29889.

Consider these detailed examples of 29888 and 29889 from Smith:

Example 1: During a level-four E/M service for an established patient, the surgeon notes that the patient’s left knee has pain and instability accompanied by a popping sensation. The surgeon orders a two-view knee X-ray, which uncovers no evidence of fracture. Then, the surgeon orders an MRI without contrast material, which confirms an ACL tear. The ACL tear is assessed and an autograft of the patella tendon of quadriceps tendon is taken. The surgeon then debrides the ACL and creates femoral and tibial tunnels. The graft is secured with a screw. A Lachman’s test is performed again to ensure stability, and the wounds are closed.

For this claim, you’d report:

• 29888 for the ACL repair
• Modifier LT appended to 29888 to indicate laterality
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99214 to show that the E/M led to the surgery
• S83.512A (Sprain of anterior cruciate ligament of left knee, initial encounter) appended to 29888 and 99214 to represent the patient’s injury

Example 2: During a level-four E/M service for an established patient, the surgeon notes that the patient’s left knee has pain and instability, along with a popping sensation. The surgeon performs an MRI without contrast material, which confirms a torn left PCL. The PCL tear is assessed, and it is determined that the surgeon will use an autograft. The surgeon debrides the PCL, then creates and secures femoral and tibial tunnels. The graft is secured with a screw and Lachman’s test is performed to ensure stability. The wounds are closed.

For this claim, you’d report:

• 29889 for the PCL repair
• Modifier LT appended to 29889 to indicate laterality
• 99214 for the E/M
• Modifier 57 appended to 99214 to indicate that the E/M led to the surgery
• S83.512A appended to 29889 and 99214 to represent the patient’s injury

Remember: A PCL tear is a much less common injury, and one that is much more suited to nonsurgical treatment. Even if the patient does have a torn PCL, initial treatment will likely not be surgical: the first treatment plan would involve a combination of crutches, bracing, and physical therapy (PT). Indications for PCL surgery would be failure to improve with PT and bracing, persistent swelling with instability, and MRI confirming a complete PCL tear.