Introduction to Orthopedic Surgery Coding Presented by Branden Chavez, CPC 07-13-2017
Disclaimer The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices.
Agenda Anatomy Basics Ligaments, tendons, and bones of the knees, hips, and shoulders Arthroscopic FAI FAI procedures and the bundling of existing scope codes Knee Arthroscopies Meniscectomies and Chondroplasties How are loose body removals reported Chondroplasties and other knee scope procedures Synovectomy coding Shoulder Issues Acrominoplasty what is needed to bill these Debridement what is limited vs. extensive Total Joints What to look for in the documentation to quickly code out total joints
I believe the world is one big family, and we need to help each other. Jet Li
Anatomy Basics Skeletal Muscles Skeletal muscles are based on their basic characteristics; size, shape, and location and/or attachments. Many muscles names are formed by using combinations of the basic word roots in medical terminology to describe a distinct attribute of that muscle. Therefore, understanding the meaning of a muscle s name gives a clue to that muscle s specific attributes. Like the bones, the skeletal muscles range in size and shape to suit the particular functions they perform.
Shoulder Joint The shoulder (or humeroscapular) joint is formed by the articulation of the head of the Humerus with the Scapula. It is a ball-and-socket joint and the most freely movable joint in the body. The shoulder joint is protected superiorly by an arch, which is formed by the coracoid process of the scapula, the acromion process of the scapula and the clavicle. It is an extremely mobile joint, in which stability has been sacrificed for mobility. Although three ligaments protect and surround the shoulder joint, most of its stability comes from the powerful muscles and tendons of the rotator cuff. The rotator cuff consists of four muscles: Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor. Each of these muscles has its origin on the Scapula and inserts around the head of the Humerus. The tendons of these muscles surround and support the Humerus while the contraction of the muscles rotates, adducts, or abducts the Humerus.
Shoulder Joint Surrounding the rotator cuff muscles are many groups of muscles that work together to produce the various movements of the shoulder. Located superior to the shoulder joint, the deltoid muscle works with the supraspinatus to abduct the arm at the shoulder. On the anterior side of the shoulder, the coracobrachialis, serratus anterior, pectoralis major, and pectoralis minor muscles work as a group to flex and adduct the scapula and Humerus anteriorly toward the sternum. The latissimus dorsi and teres major on the posterior side extend and adduct the arm towards the vertebrae of the back. Working on the pectoral girdle, the trapezius, rhomboid major, and levator scapulae muscles of the back elevate the scapula to shrug the shoulders and move the scapula posteriorly (as in reaching back behind the body).
Hip Joint The hip joint is one of the most important joints in the human body. It allows us to walk, run, and jump. It bears our body s weight and the force of the strong muscles of the hip and leg. Yet the hip joint is also one of our most flexible joints and allows a greater range of motion than all other joints in the body except for the shoulder. The hip joint is a ball-and-socket synovial joint formed between the os coxa (hip bone) and the femur. A round, cup-shaped structure on the os coax, known as the acetabulum, forms the socket for the hip joint. The rounded head of the femur
Hip Joint Cont. Ligaments of the hip joint are the Illeofemoral, Ischiofemoral, Posterior Sacroiliac, Pubofemoral, Sacrospinous, and the Sacrotuberous. These ligaments prevent the dislocation of the joint. The strong muscles of the hip region also help to hold the hip joint together and prevent dislocation.
Knee Joint The muscles of the knee include the quadriceps, hamstrings, and the muscles of the calf. These muscles work in groups to flex, extend and stabilize the knee joint. These motions of the knee allow the body to perform such important movements as walking, running, kicking, and jumping. Extending along the anterior surface of the thigh are the four muscles of the quadriceps femoris group (vastus lateralis, vastus medialis, vastus intermedius, and rectus femoris). These large muscles originate in the ilium and femur and insert on the tibia. Contraction of the quadriceps group extends the leg at the knee and flexes the thigh at the hip.
Knee Joint Cont. The hamstring muscle group extends across the posterior surface of the thigh from the ischium of the pelvis to the tibia of the lower leg. Three individual muscles form the hamstrings group: biceps femoris, semitendinosus, and semimembranosus. The hamstrings work together to flex the leg at the knee. In the calf region of the leg, the gastrocnemius muscle extends from the distal end of the femur through the calcaneal (Achilles) tendon to the calcaneus of the heel. The gastrocnemius forms the posterior muscular wall of the knee and acts as a flexor of the knee and plantar flexor of the foot. Some other muscles that assist with the movements of the knee include the tensor fasciae latae, popliteus and the articularis genus muscles. The tensor fasciae latae contracts the iliotibial band of fibrous connective tissue that helps to stabilize the femur, tibia, and thigh muscles
Posterolateral Corner The ACL, PCL, MCL, LCL are typically torn as well in these types of injuries along with the meniscus. Muscles that make up this area are the Biceps Femoris, Plantaris, Gastrocnemius, and the Popliteus. Ligaments that make up this area are the Fabellofibular, Lateral Collateral, Acruate, Popliteofibular Tendons that make up this area are the Biceps Femoris, and the popliteus. The Posterolateral joint capsule is also in this area. The CPT codes for these procedures are generally any combination of 27403, 27405, 27407, 27409, 27427, 27428, and 27429. It s extremely important to document in the operative report the ligaments being repaired vs. reconstructed.
Arthroscopic FAI 29914 Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion) 29915 Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion) 29916 Arthroscopy, hip, surgical; with labral repair
Arthroscopic FAI (Continued) CPT lays out specific bundling rules that must be followed with these codes. Do not report code 29916 with codes 29915, 29862 or 29863. This set of procedure codes also address the articular cartilage and/or labrum (the soft tissue ring or rim that surrounds the hip joint socket). Do not assign 29914-29915 with codes 29862 or 29863. This set of codes also address the articular cartilage and/or labrum (the soft tissue ring or rim that surrounds the hip joint socket).
CPT Assistant 2011 FAI is a condition in which the femoral head and acetabulum (the ball and socket) do not fit perfectly, causing friction during hip movements and resulting in damage within the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral cartilage (the soft tissue that surrounds the socket).
CPT Assistant Sept 2011-Cam There are generally two forms of FAI: cam and pincer. The cam form describes the femoral head and neck relationship as aspherical or not perfectly round. (Cam is from the Dutch word meaning cog. ) In the cam form of FAI, a bump on the femoral neck comes into contact with the rim of the socket when the hip is bent up. This loss of roundness contributes to abnormal contact between the head and socket.
CPT Assistant 2011-Pincer The pincer form of FAI describes the situation in which the socket or acetabulum has too much coverage of the ball or femoral head, often from the formation of a spur that extends out from the edge of the socket. (Pincer is from the French word meaning to pinch. ) This extra coverage typically exists along the front top rim of the socket (the acetabulum), and causes the labral cartilage to be pinched between the rim of the socket and the anterior femoral head-neck junction.
Labrum Tears The labrum is a band of tough cartilage and connective tissue that lines the rim of the hip socket, or acetabulum. It cushions the hip joint, preventing the bones from directly rubbing against each other. The labrum also helps keep the leg bone in place and increases stability of the joint. A hip labral tear involves the ring of soft elastic tissue that follows the outside rim of the socket of the hip joint.
Labrum Tears Two types of labral tears have been identified. A primary or type 1 tear is a detachment of the labrum from the rim of the acetabulum, commonly caused by a cam impingement. A type 2 tear is an intrasubstance tear of the labrum, typically caused by a crushing of the labrum against the neck of the femur by an overhanging rim of the acetabulum (pincer lesion). Code 29916 describes arthroscopic repair of the torn labrum.
Description of Procedure (29914) The patient is brought to the operating room and placed on a traction table. Distraction of the joint is verified with fluoroscopy. The hip is prepped and draped in a sterile fashion. Arthroscopic portals are established with standard technique using a long spinal needle, flexible guidewire, and a cannulated obturator and sheath. The scope sheath is inserted through an anterolateral portal. An anterior portal is then established under direct arthroscopic and C-arm fluoroscopy. A capsulotomy is performed to enable visualization in the peripheral compartment. Additional portals are created for work in the peripheral compartment. The cam lesion of the femoral head-neck junction is visualized. The area of abnormal bone is outlined with a radiofrequency device using arthroscopic and fluoroscopic guidance to assure adequate bone removal. The cam lesion is removed using a powered burr and shaver with fluoroscopic and direct visualization. The capsulotomy is then repaired. The peripheral compartment is distended with local anesthetic, the portals are closed with nylon sutures, and a sterile dressing is applied. The patient is transferred to the recovery room.
Description of Procedure (29915) The patient is brought to the operating room and placed on a traction table. Distraction of the joint is verified with fluoroscopy. The hip is prepped and draped in a sterile fashion. Arthroscopic portals are established with standard technique using a long spinal needle, flexible guidewire, and a cannulated obturator and sheath. The scope sheath is inserted through an anterolateral portal. An anterior portal is then established under direct arthroscopic and C- arm fluoroscopy. A capsulotomy is performed to facilitate resection in the peripheral compartment. The acetabular rim is resected with a motorized burr superiorly and anteriorly. Adequate resection is confirmed both arthroscopically and with fluoroscopy. Any labral detachment that has been performed to access the bony acetabular deformity is re-attached with suture anchors. The capsulotomy is repaired. The peripheral compartment is distended with local anesthetic. The portals are closed with nylon sutures and a sterile dressing is applied. The patient is transferred to the recovery room.
Description of Procedure (29916) The patient is brought to the operating room and placed on a special traction table in the supine position. Distraction of the joint is verified with fluoroscopy. Arthroscopic portals are established with standard techniques with a long spinal needle, flexible guidewire, and a cannulated obturator and sheath. The scope sheath is inserted through an anterolateral portal. The anterior portal is established under direct arthroscopic and C-arm fluoroscopy. The labrum is closely examined and probed to locate any tears and to determine the stability of the labrum. Soft tissues are elevated from the acetabulum to prepare for labral repair. A drill guide is used through an accessory portal to drill holes in the acetabular rim and suture anchors are placed.
Description of Procedure (29916) The sutures are then retrieved through the labrum in a horizontal mattress stitch using suture retrievers and graspers. The sutures are tied on the extraarticular side of the labrum to avoid contact with the femoral head. After the repair is completed, the hip capsule is repaired to minimize the risk of postoperative instability. This is done by using suture passers and retrievers brought in through the various portals. Sutures are passed through the capsular tissues and tied with arthroscopic knot-tying techniques. After the procedure is completed, the instruments are backed out of the central compartment and the traction is released. The joint is distended with local anesthetic, the portals are closed with nylon sutures, sterile dressings are applied, and the patient is transferred to the recovery room. Sept CPT Assistant 2011
4/1/2017 Orthopedic Coders pink sheet According to Margie Scalley Vaught Check with your payer before separately reporting either the psoas release or capsular plication with an FAI procedure. It s quite likely you will receive no additional reimbursement for either procedure. For example, Aetna states in its FAI policy that it considers capsular plication to be experimental and investigational for the treatment of FAI because there is insufficient evidence regarding the effectiveness of this approach. In addition, the payer says iliopsoas tendon release surgery is considered integral to the primary procedure and not separately reimbursable. Cigna also considers capsular plication to be experimental and investigational, according to its policy. This tends to be a commercial payer issue more than Medicare because the FAI condition occurs more often with young, active patients than with older ones.
Knee Arthroscopes The Knee is separated into three compartments Medial Lateral Patellofemoral The Medical Record must describe which compartment is being worked on.
CCI 2017 23.0 CPT codes 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation) and 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) should not be reported with other knee arthroscopy codes (29866-29889)
G0289 HCPCS code G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee. This code may be reported with other knee arthroscopy codes. Since 29880 and 29881 include debridement/shaving of articular cartilage, G0289 may only be reported if it is for removal of a loose body in a separate compartment. If 29880 is performed, only a loose body from the Patellofemoral compartment can be reported, if a chondroplasty isn t also performed in this compartment.
29875 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure). A synovectomy to clean up a joint on which another more extensive procedure is performed is not separately reportable. CPT code 29875 should never be reported with another arthroscopic knee procedure on the ipsilateral knee. 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)
29876 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (e.g., medial or lateral) CPT code 29876 may be reported for a medically reasonable and necessary synovectomy with another arthroscopic knee procedure on the ipsilateral knee if the synovectomy is performed in two compartments on which another arthroscopic procedure is not performed. For example, CPT code 29876 should never be reported for a major synovectomy with CPT code 29880 on the ipsilateral knee since knee arthroscopic procedures other than synovectomy are performed in two of the three knee compartments.
29879 29879-Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture Debriding down to bleeding bone Includes: Chondroplasty AND lysis of adhesions AND Synovectomy in same compartment Excludes: Removal of loose bodies IF greater than 5mm and/or thru separate incision AND Meniscectomy and/or repair meniscus. Document, Document, Document
29888 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction. Code 29888 excludes meniscectomy, meniscal repair, removal of loose knee joint bodies, chondroplasty of a separate knee "compartment," and abrasion arthroplasty. It also excludes nonlocal graft harvesting. Payer guidelines prevail. Do not assign 29888 for "thermal shrinkage" or "thermal tightening" of the ACL; instead, assign code 29999 for Unlisted procedure, arthroscopy. Payer guidelines may stipulate submission of a complete operative report when code 29999 is used.
What are the issues? Limited Vs. Extensive Debridement What is the difference and when are they not bundled? 29826: Acrominoplasty What has to be documented to be billable. 29807: Slap Top Half Of Labrum 29806 Capsulorrhaphy Bottom half of Labrum Rotator cuff interval NCCI updates creating changes from last year.
Shoulder Arthroscopes The AAOS Coding, Coverage and Reimbursement Committee recognizes three areas or regions of the shoulder: the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space These areas are clearly separate; procedures done in one area should not influence coding in a different area.
Limited vs Extensive CPT 29822 covers limited debridement of soft or hard tissue and should be used for limited labral debridement, cuff debridement, or the removal of degenerative cartilage and osteophytes. CPT 29823 should be used only for extensive debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis, and supraspinatus.
29826: Acrominoplasty 29826: Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed (list separately in addition to code for primary procedure) In 2012 this code became an add on code. Can only be billed with CPT codes 29806-29825, 29827, 29828
29826 Cont. In order to bill for the 29826 there must be mention of an acromioplasty or, a change in morphology in the acromion. If the physician just does a subacromial decompression, with a coracoacromial ligament release, this is considered a debridement and must be reported with 29822/29823. There are four types of acromion Type I (flat), Type II (curved), Type III (Hooked) Type IV (Convex). CDI recommends that physicians use these when documenting the change in morphology. For example; Type III to Type II.
During open procedures Sometimes providers will do a 29826 and then convert the procedure into an open procedure. How do I bill this? 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add on code to 23410 or 23412. An unlisted code should not be reported to reflect this work. Instead depending on what the practice decides, append modifier 22 or report 29822 or 29823.
29807 SLAP There are at leas at seven types of recognized slap lesions. I II III IV Degenerative fraying of the superior portion of the labrum, with the labrum remaining firmly attached to the glenoid rim Separation of the superior portion of the glenoid labrum and tendon of the biceps brachii muscle from the glenoid rim Bucket-handle tears of the superior portion of the labrum without involvement of the biceps brachii (long head) attachment Bucket-handle tears of the superior portion of the labrum extending into the biceps tendon
Types of slap cont. V VI Anteroinferior Bankart lesion that extends upward to include a separation of the biceps tendon Unstable radial of flap tears associated with separation of the biceps anchor VII Anterior extension of the SLAP lesion beneath the middle glenohumeral ligament
Confusion in Code selection When these codes were created in 2002, the intention was to split the glenoid into a top half and a bottom half. Work on the top half is a SLAP (29807), and work on the bottom is a capsulorraphy (29806). If the work is greater than the normal service (anterior to posterior capsulorraphy) then use the 22 modifier. If you do both the 29806 and 29807, then use the X modifier, or 59, depending on the payer s requirement.
Just remember faces on the clock
Clock Cont. Pt had a tear of the labrum from 11 o clock to 2 o clock, with anchors/sutures placed at 11 o clock, 12 o clock and 2 o clock This clearly supports upper half of the labrum. If the physician is not documenting this way, explain to him/her that this format is easier for coding and appealing if denials occur.
Crossover sections For those that bridge the gap, so to speak, the AAOS says that adding code 29806 for repair of a slap lesion is never appropriate unless there is a capsular defect in an area different than the Slap. Even if a staple or device goes through the capsule to repair a the SLAP, capsulorraphy should not be coded separately.
Reporting 29807 and 29806 A surgeon performs an arthroscopic anterior and posterior capsulorraphy. How would this be coded- CPT code 29806 is reported only once. It would be inappropriate to report this code TWICE because just one capsule is being repaired
Reporting 29807 and 29806 (Continued ) Patient presents with an anterior-inferior capsular defect resulting in instability. Surgeon performs a capsulorraphy when a SLAP 2 lesion is encountered. How would this be coded? Codes 29806 and 29807-59 are reported. Since two separate lesions were identified, this supports reporting the two codes.
Reporting 29807 and 29806 (Continued ) Patient presents with a SLAP lesion. Surgeon performs arthroscopic SLAP lesion repair. There is reference in the operative report of suture brought up through the capsule. How would this be coded? CPT Code 29807 is the appropriate code to represent this surgical technique. Since the lesion identified is that of a SLAP, the repair which includes going through the capsule for stabilization would not meet the guidelines of a "true" capsulorraphy
Reporting 29807 and 29806 (Continued ) When doing a SLAP lesion repair, the lesion is caused by the tendon pulling the labrum loose from the capsule. These types of SLAP lesions require repair. The repair is typically done by placing some sort of suture/anchor/staple through the labrum and into the bone. To do this, the staple has to go through the capsule to get to the bone, but this does not mean that a capsulorraphy was done.
Coding for Bankart Bankart (sutures or staples) Arthroscopic When using thermal to tighten, then the coder must report 29999, not 29806. The most common way to address the Bankart lesion is to repair the capsule to the glenoid by using either sutures or staples. If the capsule is loose, thermal capsulorraphy or another form of capsular reefing is done. Closure of the rotator interval is one form of capsular reefing.
Rotator cuff interval Sometimes the rotator interval is closed to address instability. If this is the only procedure done, use code 29806 Arthroscopy, shoulder, surgical, capsulorraphy. If other capsulorraphy procedures are performed to address the instability, the rotator cuff interval closure is included in the capsulorraphy and should not be coded separately. It is inappropriate to report a rotator interval closure with a rotator cuff repair.
Coding for the Rotator Cuff Rotator Cuff Repair Open Acute 23410 Young Patients Chronic 23412 Older patients; Degenerative tears Reconstruction 23420 Fascial grafting Arthroscopic 29827 With excision distal clavicle and acromioplasty 29827 29824 29826
NCCI updates In 2016 NCCI bundled 29822 and 29823 into all the shoulder codes, however, this changed in 2017. If the practice was not billing 29823 in Q1 in 2017, the presenter recommends going back and rebilling the code.
NCCI updates and Shake-ups NCCI states that 29822 is included in all other shoulder codes even if the limited debridement is performed in a different area of the same shoulder than the other procedure. With three exceptions, shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder than the other procedure. CPT codes 29824 (arthroscopic claviculectomy including distal articular surface), 29827 (arthroscopic rotator cuff repair), and 29828 (biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder.
Total Knee Arthroplasty Both the medial and lateral compartments of a knee are reshaped and a prosthesis implanted in a patient who has damage to both compartments. Menisectomy, synovectomy, debridement, and release of the lateral retinacula, ligament or capsule are all included. The Patella can be replaced and isn t billed separately.
Total Knee Arthroplasty The use of a custom prosthetic does not affect coding. The proper code for the surgery is 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) The quickest way to identify a TKA vs a partial, is by searching for components of the knee that are being replaced in the header.
Quiz Time
Thank you Branden Chavez, CPC Director, Revenue Cycle Soerries Coding & Billing Institute Branden@thescbi.com