Part B Insider (Multispecialty) Coding Alert

New Category III codes may boost payments for imaging

Roughly 14,000 Medicare patients receive a revision total hip replacement every year. This process, in which the surgeon repairs all or part of a previous total hip replacement, can be much more complex than the primary THR, but it can be tricky to obtain more Medicare reimbursement for the procedure.
 
One reason for the greater complexity of revision THRs is the fact that the existing hardware inside the patient's hip makes it harder for imaging devices to guide the surgeon. There's also a higher risk of fractures in the femoral shaft.

Luckily, surgeons have been pioneering new computer-assisted devices to increase the accuracy of revision THR operations. One recent study describes using "intra-operative C-arm fluoroscopic images" with a "novel checkerboard plate" to correct geometric distortion, plus a "corkscrew fiducical object attached to the robot end-effector."

German company Brainlab describes its VectorVision device as "a global positioning system for the body" that allows less invasive procedures and improves outcomes.

These devices are creating tremendous excitement among orthopedic surgeons, says Heidi Stout, coding & reimbursement manager with University Orthopedic Associates in New Brunswick, NJ. Her physicians "have just started doing this within the last two or three months, so we're just getting into this now." For 2004, Medicare introduced three new codes for computer-assisted musculoskeletal surgical navigational orthopedic procedures: 0054T is for fluoroscopic images, 0055T for CT/MRI images, and 0056T is imageless.

Unfortunately, "the payors just don't know what to do with these category III codes," reports Stout. Nor are the carriers familiar with this new technology. With private payors, Stout seeks prior authorization before the case even starts, but that won't work with Medicare. Her local carrier, Empire, won't even process the Category III codes. Instead, Stout submits the claim and it goes into review.

In review, Stout submits a letter in which the physician describes the patient and how it enhances surgical outcomes.

To bill for revision THRs, use 27134-27138, says Mary Brown, orthopedic coding specialist at OrthoWest in Omaha, NE. Use 27134 for both the femoral and acetabular components, or 27137 for just the acetabular and CPT 27138 for just the femoral.

Complications With Revision THRs

One common complication with revision THRs: the femoral shaft can split and the surgeon must perform a circlage around the femoral shaft to the end of the prosthesis, especially if the patient has osteoporosis, says Brown. In this case, use the -22 modifier to denote the extra work involved.
 
Likewise, there's always a risk of fracture with knee or hip revision, so if the physician must repair a fracture, you'd either add on the fracture code or use the -22 modifier.
 
If the patient has comorbidities such as diabetes, this may increase the level of evaluation and management services before surgery, but won't boost surgical reimbursement itself, says Brown.

Editor's Note: See www.brainlab.com/english/physician_info/ortho/html/py_orthopedics_what_is_igs.html for more information on VectorVision.