Orthopedic Coding Alert

Remember payer guidelines to choose accurate comparisons.

You may find that CPT® 2015 doesn’t resolve all your coding quandaries. For instance, when your orthopedist performs an arthroscopic biceps tenotomy or open microfracture of the knee, CPT® still doesn’t include any codes that “fit.” 

That means you’re stuck with reporting an “unlisted procedure” code, but that doesn’t mean you won’t receive adequate payment. Follow a few simple steps to improve your claim’s chances with the payer.

Never Choose a ‘Close’ Code

If CPT® includes a code that’s close to the procedure your surgeon performed but not a perfect fit, steer clear. CPT® guidelines clearly state you should report the service “using the appropriate unlisted procedure or service code.”

CPT® does not include a code for every possible procedure, despite all the additions and revisions each year. You fill the gap with the most appropriate unlisted procedure code, such as 27899 (Unlisted procedure, leg or ankle) or 29999 (Unlisted procedure, arthroscopy). The better your surgeon documents the procedure, the easier — and more accurate — your code selection will be.

Use Easy-to-Understand Terms

Always include a cover letter with your claim explaining why you chose an unlisted procedure code. Use simple, straightforward language to explain exactly what the surgeon did and why an unlisted code fits best.

Documentation tip: Ask your physicians to include information at the top of the operative note explaining the procedure, why he or she believes you should report an unlisted code, and a comparable procedure and code for setting reimbursement. You can use this information in your cover letter to the payer.

The trick with unlisted codes is making the carrier understand what the surgeon has done, experts say. Claims should be dropped to paper with a letter of explanation attached.

Timing: Submit your claim electronically with a short description of the procedure in the electronic equivalent of box 19 of the CMS-1500 form. Follow up with the paper claim and documentation and include a note stating that you’re sending a “documentation” copy, not a duplicate copy. Filing electronically proves you submitted the claim in a timely manner.

Select a Comparison Code

The Medicare Physician Fee Schedule does not include unlisted procedure codes, so the codes don’t have assigned fees or global periods. When you submit an unlisted code, suggest a fee by comparing the procedure your surgeon completed to a similar procedure with a “real” CPT code and established reimbursement value.

Example 1: For the arthroscopic biceps tenotomy above, report 29999. When setting reimbursement, experts recommend comparing the procedure to 23440 (Resection or transplantation of long tendon of biceps), which carries 19.82 relative value units (RVUs).

Example 2: Code 29879 (Arthroscopy, knee, surgical; abrasion arthroplasty [includes chondroplasty where necessary] or multiple drilling or microfracture) represents arthroscopic treatment for microfracture of the knee (drilling for a chondral lesion). Most surgeons perform the procedure arthroscopically, which simplifies your coding. If your surgeon performs the open procedure, however, you won’t find a clear option in CPT®. Report 27599 (Unlisted procedure, femur or knee) and compare the fee and RVUs to 29879 (which carries 18.95 RVUs).

As you select a comparison code, remember that you might be able to report more than one. Medial reefing, plications, and/or trephination is a somewhat common arthroscopic procedure on the knee that requires an unlisted code. A combination of compare-to codes usually must be reported for the procedure.

Know Your Payers’ Expectations

Keep updated on all your payers’ guidelines, but especially workers’ compensation.

Here’s why: Workers’ comp payers can be slower to adopt new codes or adjust fee schedules than other insurance companies. This means some workers’ comp payers may base their fee schedule on an older version of CPT®, which leaves out many orthopedic procedures that CPT® added since that year.

Result: Submitting claims with current codes can lead to denials because the insurer doesn’t know what to pay for codes not on the fee schedule. Try using comparison codes that date back to the payer’s schedule to smooth processing.

Warning: You may have to wait, because it always takes much longer to get an unlisted procedure paid. Some coders always send operative notes with the claim and sometimes send an article explaining the procedure. For some insurance companies, many coders call and fax everything to the medical director for review and authorization ahead of time.