Wiki 27487 and 27438

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yvetteprater

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My Doctor always wants to bill these two codes together if he revises the patella at the same time. Is there any circumstance in which these two codes can be billed together. I have been researching but am finding nothing that supports. Thank you for any feedback
 
yvetteprater said:
My Doctor always wants to bill these two codes together if he revises the patella at the same time. Is there any circumstance in which these two codes can be billed together. I have been researching but am finding nothing that supports. Thank you for any feedback
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Yes, if they are performed on opposite knees. However let's address the elephant in the room. You say that your doctor always wants to bill these codes together. Code 27487 is rarely performed. It sounds like this code is being billed on a regular basis. If that is true, something is not quite right.
 
That is one of his specialties. These are new patients, not revising his own work. He does do quite a few, but he doesn't always bill the patellar. If it is revised, he feels that is a separate procedure. Am I correct in thinking that when using the modifier 59, it would be put on 27487. That is what is confusing to me. But, you are saying ONLY on opposite knees is appropriate?
 
yvetteprater said:
That is one of his specialties. These are new patients, not revising his own work. He does do quite a few, but he doesn't always bill the patellar. If it is revised, he feels that is a separate procedure. Am I correct in thinking that when using the modifier 59, it would be put on 27487. That is what is confusing to me. But, you are saying ONLY on opposite knees is appropriate?
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Correct. And the reason is that they are "Mutually Exclusive" procedures. A revision is where both components are removed and replaced during the same surgical session. That almost never happens. Usually one of the components becomes loose and gets replaced or there is infection and the components are removed and an antibiotic spacer is put in. The -59 will go on the procedure with less RVU value. The first thing that I would do is verify that a true revision is being performed, and not just a poly or component swap.
 
Yes, that is why its coded 27487. I will just have to tell him that patella is included. Thank you for your input!! Much appreciated.
 
I agree this is a revision TKA 27487, you can't take separate credit for the patella. Plus, the patella had been addressed in the prior surgery because they talk about poly wear of the patella button and it "fell off". I was wondering, before I read it, if this was one where in the initial TKA the patella was not addressed. I have seen instances where an initial TKA is done but the native patella is left, then when they go in to do a revision TKA they address it then. Even in that scenario, you still can't get credit for a 27438. I was wondering if that was a confusion. After reading this one, that is not the case.

I understand where the confusion comes in, because the cpt description only mentions the femoral and tibial component, however the patella is included. I think there may be some CPT Assistant articles too if you can access that. If the provider thinks that there was extensive extra work over and above a normal revision TKA, they would have to document that and you "might" be able to append a modifier 22. It would have to be super-clearly documented and supported. I read the part about the bone loss and reconstruction of the patella and am wondering if that's what he is trying to report 27438 for? The bone loss and reconstruction? The current documentation is not enough to support a 22 but if the provider feels that this goes over and above the normal "work" for a revision that didn't require this, the documentation would have to be improved. This is a discussion you'd have to have with the surgeon.

It would have to support: Increased intensity, Time, Technical difficulty of procedure, Severity of patient’s condition, Physical and mental effort required.

If you look at the work RVUs for 27487 (27.11) you can see the revision aspect and what goes into that type of case are taken into account. https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=3&H1=27487&M=5

@Orthocoderpgu is correct, 27438 is pretty uncommon to see these days.

Helpful webinars (there is one specific to arthroplasty): https://karenzupko.com/bundle-1-the...lasty-from-a-to-z-fracture-care-step-by-step/

additional reference: https://www.thehaugengroup.com/cpt-coding-for-joint-replacement/
 
Thank you so much! I am going to review all the references you provided! When I do research on my own, I don't always know where to look. This will be very helpful.
 
yvetteprater said:
Thank you so much! I am going to review all the references you provided! When I do research on my own, I don't always know where to look. This will be very helpful.
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Understand where your surgeon is coming from. They know that there are CPT codes for every surgical procedure and they just "list" them at the end of a surgical session and it's hard for them to look at it from a coding perspective. So they have a hard time wondering why all the codes are not always billable. One reason why coders and providers have to work together.
 
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