Wiki 20900 vs 20902

[kamer330]

Hi, we are having a debate in the office concerning which code to use 20900 Bone graft, any donor area; minor or small (eg, dowel or button) or 20902 major or large. The surgeon documents:

At this time, under fluoroscopy, the lateral wall of the calcaneus was marked out. Then, a 2-cm incision was made on the lateral wall. The incision was deepened through subcutaneous tissue with care to identify and retract all the neurovascular structures. The periosteum of the lateral wall of calcaneus was reflected. At this time, an Acumed drill bit harvester was utilized and a dowel sized calcaneal autograft was obtained and set on the back table for later use. The lateral wall incision was copiously lavaged with normal saline and closed with nylon.

The graft was used to fuse the metatarsalcuneiform joint. Any feedback would be appreciated.

 

[amyjph]

You answered your own question = dowel.

20900 Bone graft, any donor area; minor or small (eg, dowel or button)
"At this time, an Acumed drill bit harvester was utilized and a dowel sized calcaneal autograft"

Also, think about the size of the joint it's being put into. It's would be rare to impossible to be major or large when it's being put in a single TMT. Did they do anything else during the case though? Were they at the calcaneus for any other reason? Was is a multiple TMT or single fusion? If it was multiple it is "possible" it could be bigger but I highly doubt it and this particular report it would not be because they said the word dowel.

 

[christinaob]

You answered your own question = dowel.

20900 Bone graft, any donor area; minor or small (eg, dowel or button)
"At this time, an Acumed drill bit harvester was utilized and a dowel sized calcaneal autograft"

Also, think about the size of the joint it's being put into. It's would be rare to impossible to be major or large when it's being put in a single TMT. Did they do anything else during the case though? Were they at the calcaneus for any other reason? Was is a multiple TMT or single fusion? If it was multiple it is "possible" it could be bigger but I highly doubt it and this particular report it would not be because they said the word dowel.

So we had TCN help code some of our reports when we were down a staff member and they code the above report as 20902 - when we inquired as to why this is their response:
Please tell us what you make of this.

Inquiry:
In the AAOS bulletin February 2002, we are instructed that the bone graft is dependent on the bone from which the graft was obtained "Usually what is meant by minor or small (20900) is the place selected (anatomy site) for the bone graft such as the radius for scaphoid fracture grafting; major or large (20902) is used for iliac crest or larger anatomy structures." Would the bone graft from the calcaneus (the largest bone in the foot) and the metatarsal be considered a large enough bone to support CPT 20902 (Bone graft, any donor area; major or large)? The calcaneus bone volume comparison is similar to that of the iliac crest and is far larger than the distal radius as stated in the AAOS example for CPT 20900 (Bone graft, any donor area; minor or small (eg, dowel or button). Example 1: If a 1 cm incision was made over the posterior tuberosity of the right calcaneus and dissection was carried down through skin and subcutaneous tissues down to bone, then a 1 cm window in the bone was then made and utilizing a curette, with removal of about 3 mL of autologous cancellous bone graft from the heel. Example 2: If a Y-shaped capsulotomy was made over the first MTP exposing the medial eminence. This was resected parallel to the medial border of the bone with a microsagittal saw as was the dorsomedial prominence removed with a rongeur.

AMA Response:
From a CPT coding perspective and based solely on the information provided in your inquiry, the following comments are made in reference to the excerpt from the American Academy of Orthopaedic Surgeons (AAOS) February 2002 Bulletin: “Usually what is meant by minor or small (20900) is the place selected (anatomy site) for the bone graft such as the radius for scaphoid fracture grafting; major or large (20902) is usually what is used for iliac crest or larger anatomy structures.” According to AAOS’ statement, the bone graft is determined by the placement site of the graft rather the site of harvest which is indicated in the descriptions in Examples 1 & 2 of your inquiry. Therefore, if the autologenous bone graft was being implanted in the calcaneous or metatarsal sites, it would be appropriate to report code 20902, Bone graft, any donor area; major or large, for implantation in these sites. As stated in the December 2000 CPT Assistant, “The bone graft codes 20900 and 20902 are separately reportable only when the graft material is an autograft and is obtained through a separate incision and not listed as part of the basic procedure. Bone bank bone is not reported using these codes.” Thank you for your inquiry and we hope that this information is of assistance to you. CPT Education and Information Services

 

[amyjph]

My opinion is I disagree; they are incorrectly interpreting and paraphrasing what the AMA and AAOS stated. The AMA is stating, "From a CPT coding perspective and based solely on the information provided in your inquiry, the following comments are made in reference to the excerpt from the American Academy of Orthopaedic Surgeons (AAOS) February 2002 Bulletin: “Usually what is meant by minor or small (20900) is the place selected (anatomy site) for the bone graft such as the radius for scaphoid fracture grafting; major or large (20902) is usually what is used for iliac crest or larger anatomy structures.” According to AAOS’ statement, the bone graft is determined by the placement site of the graft rather the site of harvest which is indicated in the descriptions in Examples 1 & 2 of your inquiry. Therefore, if the autologenous bone graft was being implanted in the calcaneous or metatarsal sites, it would be appropriate to report code 20902, Bone graft, any donor area; major or large, for implantation in these sites. As stated in the December 2000 CPT Assistant, “The bone graft codes 20900 and 20902 are separately reportable only when the graft material is an autograft and is obtained through a separate incision and not listed as part of the basic procedure. Bone bank bone is not reported using these codes.” Thank you for your inquiry and we hope that this information is of assistance to you. CPT Education and Information Services"

In your example above, the place selected (anatomy site) for the bone graft is the TMT joint (metatarsalcuneiform joint.) which is not large by their examples above. It is not clear if it was one TMT or multiple from the section of the report. In their first sentence of the inquiry paragraph they are talking about where the graft is being taken from, not where it's being implanted to, which is not correct. That's not what AAOS is instructing. I have not seen that 20+ year old bulletin though.

Read the first sentence in the inquiry section. "bone from which the graft was obtained". Then read the third sentence in the AMA response, "the bone graft is determined by the placement site of the graft rather the site of harvest". It's two totally different meanings. Where they took it from versus where it's being placed into.

And again, if the report excerpt from above is exactly what is says, it literally says the word dowel. It doesn't matter that it came from the calcaneus, it matters where they put it and how large. Plus, it also says, "Acumed drill bit harvester " not curette or rongeur. Look up the differences of the three instruments.