Wiki Coding - Facility vs Surgeon

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sybutler

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I work for a WC insurance company. A little background, the patient suffered a fracture of left tib/fib in September 2022 and had surgery to repair it. He has surgery again in January 2023 to remove the hardware. The surgeon removes the hardware and places the patient in a circular external fixation device.

I am reviewing an outpatient facility bill. The patient was admitted for hardware removal and the facility billed 20680 along with labs, supplies, anesthesia, pharmacy, recovery room, etc. related to the service.

The surgeon billed 27828-LT, 20692-51 LT and 20680-51 LT.

My question should the facility be billing the same surgical codes as the surgeon. My boss is questioning if the facility billed correctly. If the facility billed like the surgeon, the reimbursement would be less.

I am of the opinion that the facility and surgeon’s bills are not always the same, but now I question if I am looking at this correctly. Where can I find documentation regarding this?

Any assistance in clarifying this for me would be appreciated.



Sue B.
 
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The surgical codes should be the same because they both are supported by the same operative report. There are a few situations where payers (Medicare in particular) will require a different HCPCS code from the facility than what the physician uses, but those are rare. If you are seeing different CPT codes from the physician than from the facility, then most likely one or the other has coded the records incorrectly. But without reviewing the operative report, there’s no way to know which is correct.
 
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Something is really off here. You would never bill 27828, 20692 and 20680 on the same date of service or even the same hospital visit. I can see 27828 being billed in September as the primary surgical procedure. From what I have seen with pilon fractures they usually don't remove the hardware unless there is pain or migration of it. Scheduling removal of hardware (20680) and coming out the hospital with a multiplane (20692) does not make sense either. The provider would not have scheduled hardware removal without current X-rays especially if there were problems. Unless the initial treatment (27828) failed, you would not from that to a multiplane external fixator without major issues unless the external fixator is treating something else which is doubtful. If you can post a redacted op note. Nothing is adding up. I have been coding orthopedic surgeries for ten years and have never seen anything close to this. The fact that the facility coders billed 20680 could be telling.
 
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Attached is the op report. Thank you all for you feedback.
 

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  • Redacted Op report - Facility vs Surgeon Coding.pdf
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Coding is not correct on this in my opinion. The facility is "more correct". This wasn't just a simple hardware removal (I agree with @Orthocoderpgu pilon hardware is not normally removed later and not 4 months later). This was failure of internal fixation with deformity. My first question would be why? Was the patien noncompliant with weightbearing instructions, do they smoke, do they have other co-morbidities (diabetes?), was it a really bad open fracture with tenuous fixation in the first place which caused the motion within 4 months? Is there staph in there? Is this now considered nonunion (not sure since only been about 4 months but was there any healing at all, there's not really any info on that)?

Per the op note, this was revision fixation of the pilon fracture (failure/gross motion at fracture site). The procedure header of the op note isn't great, it should say external fixation application or something besides revision because that makes you think ORIF but it wasn't when you read it. Sounds like someone coded it from the header of the op note without reading it.
There is no revision ORIF (27828) described in this op note. It was hardware removal and application of an ex-fix (20692 Ilizarov). I might actually expect to see 20680, 20692 on this since there was no ORIF yet. I'm sure they are staging it for later. They will possibly keep the ex-fix on and go back in later. Maybe not but can't see how this will heal with just ex-fix.

Side note- Removal of hardware (20680, 20670) in the course of a revision ORIF is not separately billable. Also, an ex-fix would likely never be applied for simple hardware removal, if it needed an ex-fix they wouldn't remove the hardware alone. They only remove it if the fracture is stable/healed. I would also want to see the labs from the cultures taken from the fracture site.

References:
"10. There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable."
 
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