Orthopedic Coding Alert

Tip: Including an explanation in the op note will streamline your claim.

Suppose an operative note lands on your desk where an orthopedic surgeon describes a laminotomy and excision of herniated thoracic disc. When you consult your coding manual, you find the only thoracic codes correspond to transpedicular or costovertebral approach. So what should you do?

Solution: Turn to an unlisted code. But before you submit your claim, make sure you follow these simple steps to show your carrier what to do with your unlisted-procedure claim.

Step 1: Never Select a “Close but Not Quite” Code

You should never report a code that comes close to the procedure your orthopedist performed but doesn’t quite fit. If no precise procedure or service code exists, you should report the service “using the appropriate unlisted procedure or service code,” state the CPT^® “Instructions for Use” in the CPT^® manual.

CPT^® includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT^® descriptor available.

Payment for such claims, however, is not automatic. Your orthopedist must make a careful effort to document the procedure, and the information you include with your claim can make all the difference.

Step 2: Explain the Procedure in Layman’s Terms

Any time you file a claim using an unlisted procedure code (for example, 27599, Unlisted procedure, femur or knee; or 29999, Unlisted procedure, arthroscopy), you should include a cover letter stating why you are using the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did.

Physician tip: “What I do is include a paragraph at the top of the op note explaining what the procedure was, why I used 29999, what code I compare it to, and so on,” says Bill Mallon, MD, former medical director of Triangle Orthopaedic Associates in Durham, N.C. “This is the same as a cover letter but in the op note.”

Part of a coder’s job when coding and preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman’s terms. You may even want to include diagrams or photographs to better help the person reviewing your claim understand the procedure.

When reporting unlisted procedures codes, do everything you can to make sure you get paid what you think is appropriate. Overload the payer with information and always give them a way to contact you with questions.

Why: Your payers will consider claims with unlisted procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don’t always dictate the most informative notes.

If the person making the payment decision doesn’t understand what the physician did, your reimbursement probably won’t properly reflect the effort involved, says Barbara Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Supply documentation: Since most carriers will no longer accept paper claims, submit your unlisted procedure code electronically with a short description of what was done in the electronic equivalent of box #19 of the CMS-1500 form. “I also recommend first sending in the claim electronically without the documentation so that you have proof of timely filing, and then sending the documentation with a statement on the claim saying that this is a -documentation copy, not a duplicate copy,” Cobuzzi says.

Include the complete operative note and an explanatory cover letter.

Step 3: Reference an Existing Code

Unlisted procedure codes do not appear in the Medicare Physician Fee Schedule, so they do not have assigned fees or global periods. Your payers will generally determine payment for unlisted-procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar, listed procedure with an established reimbursement value. This will help put your service in perspective with something they are familiar with, experts say.

Best bet: Rather than leave it up to the insurer to determine which code is the closest to what your orthopedist performed, you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination.

Tell the carrier how the procedure you-re coding for compares to, and differs from, the assigned procedure code, Cobuzzi advises. Answer these questions: “Was the unlisted procedure more or less difficult than the comparison procedure? Did it take longer to complete and, if so, by how much (try to provide percentages whenever possible)? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill, or equipment?” Any of these factors can make a difference in the reimbursement level you may expect.

Example: CPT^® does not include a code to describe laminotomy and excision of herniated thoracic disc (the only thoracic codes correspond to transpedicular or costovertebral approach). CPT^®, however, does include codes to describe cervical (63020, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical) and lumbar (63030, …one interspace, lumbar) excisions.

To report thoracic laminotomy, you may cite 64999 (Unlisted procedure, nervous system) and include an explanation with the claim stating, “Surgeon performed laminotomy with discectomy, similar to that described by 63020, but occurring in the thoracic region. Due to the anatomic difference in vertebrae structure, the work involved was roughly 10 percent greater than that described by 63020.”

Step 4: Appeal When Warranted

Even the best documentation won’t always get you the reimbursement your orthopedist deserves for an unlisted procedure. “If payment is not appropriate, you may need to appeal it,” Cobuzzi says.

Good advice: Get the name and department to whom you can send your unlisted procedure claim. That way, you can follow up your request.

If your orthopedist uses equipment and techniques that have no dedicated CPT^® codes, such as the Da Vinci robot for selected laparoscopic procedures, you may be able to enlist the manufacturer’s aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies.

Sometimes manufacturers- representatives will have helpful documentation about the equipment or technique that you could use as a second resource. But don’t rely on the reps to assist you with the coding aspect of the service.

You also can turn to specialty societies for help with appeals and documentation.

Good practice: When your orthopedist repeatedly performs the same type of unlisted procedure, prepare an information file so you don’t have to reinvent the wheel every time you submit a claim. Each time a carrier denies a similar claim, you will already have an appeals packet ready to send the payer to defend your claim.