The Orthopaedic Coding Coach 2010 Orthopaedic Coding Tips By Karen Zupko & Associates Use of Modifiers October 14, 2010 I was recently told that when applying more than one modifier, they should be listed in descending order. For example, list modifier 59 first, then modifier 50. Is this correct? Thanks for seeking clarification. Sometimes the rules and recommendations get confusing. When submitting surgical procedures, it is correct to submit modifiers in descending value order. However there s another rule to guide the order of modifiers. When CPT codes require multiple modifiers, the modifier that best differentiates the service or protects reimbursement should be first and other modifiers follow in order of sequencing. For example, if you are reporting services for an Assistant Surgeon, Modifier 80, 81, or 82 will always be the first modifier added to the Assistant Surgeon s surgical CPT code (s). Modifier 50 or 59 would be added as the second modifier, only if appropriate. While in this example the numerically larger modifier is listed first, the sequencing is based on modifier definition, not based on numeric value. The concept of modifier 50 and 59 can be confusing in themselves. So let s take a look at some examples with other modifiers. A patient is seen for a twisting knee injury while in the post-operative period of a rotator cuff repair. The orthopaedic surgeon evaluates the patient s new problem and decides to aspirate the knee. In this scenario, you would report: 992xx-24, 25 for the E&M service 20610-79 for the aspiration of the knee Modifier 24 is required to indicate the E&M is unrelated to the global period of the rotator cuff repair. Modifier 25 is required to indicate the E&M is the significant separate E&M service on the same day as the minor procedure. Modifier 79 is added to the surgical procedure to indicate the joint aspiration is in the knee and not the shoulder. Note, in the E&M example, Modifier 24, the "smaller" numeric modifier is listed first because it is necessary to first bypass the payer s post-operative global period edit. Soft Tissue Tumor Codes and Wound Closures September 30, 2010 Our surgeon is performing a complex closure for a procedure defined by one of the new soft tissue tumor codes found in the Musculoskeletal section of the CPT book. Our surgeon heard that we could report a complex closure in addition to the surgical resection. We would like to verify if this is indeed true, and if so, does that mean any surgical procedure that requires a complicated closure should be billed separately? The new and revised soft tissue tumor codes brought with them very specific coding guidelines applicable to these codes only. According to CPT 2010, extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which may be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. According to this definition, if a complex closure is required and performed for reasons other than closure secondary to elevation of the tissue planes, the complex closure may be reported in addition to the surgical procedure For example, a surgeon performs an excision of 3.5 cm (including margins) subfascial tumor of the right forearm and a 7.0 cm complex closure of the wound. Assuming medical necessity of the closure other than that
necessitated by the dissection/elevation of the tissue planes, the surgeon may report the both the excision and complex closure. Based on the above example the surgeon may report: 25073 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (e.g., intramuscular); 3 cm or greater 13121-51* Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm *Note: According to CPT rules modifier 51 is the most appropriate modifier. Medicare has a CCI edit in place bundling the repair into the resection code, thus a modifier 59 will be required. Spine Instrumentation Removal Don t Confuse the Rules! September 16, 2010 Our patient had a previous anterior fusion at C5-6. During the subsequent surgery for the fusion of C6-7, the surgeon placed a new plate at C6-7 and removed the plate and screws at C5-6. Would the removal of the plate and screws from C5-6 be a billable procedure? I say no, because it occurred through same incision, but the surgeon says yes. I have always understood that hardware removed from the same incision is included in the surgical procedure. Can you weigh in on this, and let us know the correct answer? This is a great question and your comment about the hardware removal from the same incision identifies the correct rule that needs to be understood. The guidelines in each section of CPT direct us on the rules associated with the codes within that section. In the spine section, there are instructions on the removal of instrumentation and the removal of instrumentation with reinsertion. These rules have no mention of separate incision, but focus on the location of the instrumentation, where it is removed from (anterior, posterior, segmental, non segmental) and reinserted (hardware removed and reinserted at the same anatomic location). In your scenario, it would be correct to report 22845 for the insertion of a new plate at C6-7 and 22855-59 for the removal of the plate and screws at C5-6. Now, let s take a look at the separate rule requirement in other orthopaedic procedures. If the surgeon removes hardware, for example bimalleolar screws (tibia and fibula) and two separate incisions are made, the surgeon reports 20680 and 20680-59 assuming the hardware removal is deep. In this case, the surgeon can report the code twice because the hardware is removed from 2 separate bones and 2 separate incisions. Consider a case where the surgeon treats a non-union/malunion and removes hardware through the same incision/same site to repair the non-union. The hardware removal is not separately reportable because it is through the same incision, at the same site, and is necessary to repair the non-union. Other rules apply throughout the CPT book related to other orthopaedic procedures. So, while the general guideline is hardware removed through the same incision is not separately reportable, it is critical to understand the rules associated with each procedure and section of CPT. Drainage of Seroma in the OR September 2, 2010 Our surgeon returned a patient to the OR for the drainage of a seroma and drain placement two weeks after a total hip replacement. How do I code for the seroma and drain placement? There is no CPT code for the placement of the drain associated with the seroma drainage.
Look at CPT code 10140, Incision and drainage of hematoma, seroma or fluid collection as a code option based on the surgeon s documentation. The placement of the drain is inherent to the drainage procedure and not separately reportable. Append modifier 78 to the appropriate surgical procedure as the patient is in the global period of the hip surgery. Hardware Removal August 19, 2010 The surgeons I work with do not do their own coding. One surgeon returned a patient to the OR and documented the removal of an external fixator and pins. Do I report CPT codes 20694 and 20680 for this work? No, the removal of the pins is integral to the removal of the external fixation device, thus the definitive procedure is the removal of the external fixator, 20694 Removal, under anesthesia, of external fixation system. If the patient is in the global period, you will need to append either modifier 58 or modifier 78 as appropriate. Intraoperative Fluoroscopy and Spine Surgery August 5, 2010 Our spine surgeon uses intraoperative fluoroscopy during surgeries and wants to know if this is separately billable during lumbar discectomy/fusion surgical procedures? I have not found anything that says whether it is allowed separately or not. Intraoperative fluoroscopy during spine surgery is considered to be an integral part of the procedure and is not separately reportable. Fluoroscopy is a continuous x-ray beam that creates a sequence of images that are then transmitted to a monitor, which allows the provider to evaluate the static or dynamic evaluation of the structure(s) in question. Still images can be captured on film or electronically on a computer, and contrast can be used when necessary (AMA CPT Assistant June 2008). In the case of spine surgery, the surgeons do not use fluoroscopy continuously and do not require sequenced images, but instead use it to verify a final location. As such, fluoroscopy is considered an integral part of spine surgery and is already valued into the codes for placement of instrumentation. Additionally, if you look at the AAOS Global Service Data Guide, numbers 6 and 7 of the Intraoperative Services include this type of imaging in the surgical procedure, and thus it is not separately reportable. 6. Intraoperative photo(s) and/or video recording, excluding ionizing radiation 7. Intraoperative supervision and positioning of imaging and/or monitoring equipment by operating surgeon or assistant(s) Lidocaine and Joint Injections July 22, 2010 I recently read that J2001 is unbundled in the recent CCI edits, and I can now report this code when our surgeon is administering joint injections. Is this correct? J2001 Injection, Lidocaine Hcl for Intravenous Infusion, 10 Mg does have a CCI edit modifier of 1 in the list of Column 2 codes associated with CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa). However, this edit does not allow an orthopaedic surgeon to report J2001 with CPT code 20610 for the administration of lidocaine.
There are several things to think about when reading such information. Just because Medicare may allow reporting of a code combination, the combination must represent correct coding first and foremost. 1. All surgical procedures include local anesthesia. Granted, drugs may be reported in addition to the surgical procedures as appropriate, but J2001 is not the correct code! 2. J2001 describes Lidocaine for Intravenous (IV) infusion, which is not the drug administered for a joint injection. IV lidocaine is used for the treatment of cardiac arrhythmias, not as a local anesthetic! 3. There is no Lidocaine J code to describe the lidocaine injected at the time of a joint injection. Medicare deleted J2000 around 2004. If one looks at the CCI edits, J2000 shows the deletion in April 2004. 4. Code according to the AMA CPT rules. Review codes for accuracy when reporting services. Just because Medicare reverses a CCI edit does not automatically mean that the door is opened wide for reporting code combinations that are not correct coding according to CPT. Non-Physician Provider Billing During the Global Period July 8, 2010 Our orthopaedic surgeon recently employed a physician assistant in the office. The physician assistant is seeing patients on rounds in the hospital, and he recently submitted a charge for a 99232 on a Medicare patient who was post-op for a total hip arthroplasty. The documentation for the visit all pertained to the hip arthroplasty. Can he report this E&M service when the patient is in a global period? He says yes, because he did not assist and is not in a global period. Great question and one of increasing concern as it relates to one of many issues related to Non- Physician Provider billing. We appreciate your attentiveness and raising the question. While the physician assistant (PA) was not involved in the surgery, he is employed by the surgeon who performed the surgery; thus all visits related to the surgical procedure are included in the global period, and not reportable whether performed by the surgeon or the PA. If the visit was for an unrelated problem that was evaluated and managed, the service would be reportable by the surgeon or the PA, and a modifier 24 would be appended to the E&M and the appropriate unrelated diagnosis linked to the E&M. Operating Microscope June 24, 2010 How do you code for the use of a microscope for multiple procedures? For example, the surgeon documented the microscopic repair of 6 digital nerves. Should I report the microscope code (69990) for each nerve or just once for the whole case? While the surgeon documents the use of the operating microscope (CPT code 69990) for the repair of each nerve, the CPT code may only be reported one time per operative session. Remember, CPT code 69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) is an add-on code, thus must be listed on the CMS 1500 claim form immediately following the nerve repair code. Also, as this is an add-on code, do not append modifier 51 and watch your reimbursement closely to ensure you are reimbursed at 100% of the allowable amount. Allograft Included with ORIF? June 10, 2010 Our surgeon performed and documented an ORIF of a left distal radius fracture and also placed allograft bone. Is there a CPT code for the allograft or is it included in the CPT code for the ORIF of the fracture?
This question is being asked with increasing frequency. While there are codes for allografts in the spine, there is no CPT code for the placement of an allograft for non-spine procedures. Placing the allograft chips is included in the payment for the ORIF and is not separately reportable. No Global Days for Assistant Surgeon Different Practice May 27, 2010 We work with several surgeons as assistants. When our surgeon is the assistant, we report the CPT codes with a modifier 80. Do we enter into the associated global period (typically 90 days)? Our surgeon does not see the patient during the post operative period should he? An assistant surgeon is reimbursed for assisting on the intra-service portion of a procedure. As such, the assistant surgeon does not have a global period. There is no need for your surgeon to perform postoperative services as the reimbursement for his role as assistant does not include any postoperative care. Multiple Metacarpal Fractures: Modifier 51 or Modifier 59 May 13, 2010 Our surgeon performed an open reduction, internal fixation of three metacarpal fractures, specifically the 3rd, 4th, and 5th metacarpal. I found the correct code, CPT code 26615 and now wondering if I should report this as 26615, 26615-51, and 26615-51. The code description states that the code can be reported for each bone. Yes, you are correct in your interpretation of the use of this code for each metacarpal fracture. Consider using modifier 59 (distinct procedural service) on the second and third fracture to indicate different location. Modifier 51, multiple procedures will not indicate that the fractures were at different locations, thus carriers may deny 26615-51 and 26615-51 as duplication of the first code. The claim will look as follows: 26615 26615-59 26615-59. The third fracture may still pose a reimbursement risk and be denied as duplicate necessitating an appeal. Hammertoe Repair April 29, 2010 Our practice has recently recruited our first foot-and-ankle physician, so coding for foot procedures is new to us. The physician is positive he can bill CPT code 20650, Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) in addition to CPT code 28285 for the repair of the hammertoe. From what we have read, this combination does not sound right. Is CPT code 20650 separately reportable or not? Thanks for your inquiry early in his tenure with the practice. You are correct to seek additional input to this question. First, CPT code 20650 is a separate procedure code, which means it is included in other procedures at the same site as being integral to a more comprehensive procedure. Additionally, CPT code 28285 includes internal fixation as an inclusive component of the hammertoe repair. Thus, CPT code 20650 is not separately reportable with CPT code 28285. Modifiers for Finger Procedures April 15, 2010
Our surgeon performed a PIP joint arthroplasty on the right index, middle and ring fingers. We submitted to the payor with the appropriate CPT code and the finger modifiers, F6, F7 and F8. Our payor reimbursed the procedure with the F6 modifier but denied the same procedures with the F7 and F8 modifiers as duplicate. Can you explain what I could have done differently? This is a great question and one we frequently see in hand surgery coding. You were correct to assume that the use of the finger or F modifiers alone should differentiate the location of the procedure. However, we are finding many payors also want the modifier 59 to differentiate the procedures and then the F modifier to identify the location. When this occurs we recommend reporting 26535 (assuming this was the procedure to support the PIP joint arthroplasty) as follows: 26535-F6 26535-59, F7 26535-59, F8 As we perform auditing services across the country and assist with appeals we find that the payors want both modifiers. Removal of Shoulder Implant April 1, 2010 Our surgeon dictated an operative note where the procedure title is listed as: Removal of foreign body of the shoulder, hemi and conversion to total shoulder arthroplasty. He wants to report CPT code 23331, and I want to report CPT code 20680. Which is correct? Without an operative note to respond to, we assume the surgeon is correct based on the procedure title CPT code 23331 Removal of foreign body, shoulder; deep (e.g., Neer hemiarthroplasty removal) is reported when a patient has had a previous hemi-arthroplasty and the surgeon must remove the implant. The work associated with this procedure is more complicated than removal of a deep implant (20680) which is used for removal of deep screws, plates, intramedullary nails. Since the surgeon is converting to a total shoulder, the surgeon will also report CPT code 23472, Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder) as the primary procedure followed by CPT code 23331-51. There is no CPT code for a conversion to total shoulder, thus the surgeon may consider appending modifier 22 if the documentation supports significant additional complexity over and above a primary total shoulder procedure. If the patient is in a global period, append the appropriate global period modifier. Synvisc-One March 18, 2010 Our Surgeons have started using Synvisc-One. How do we report this to the payors? Synvisc and Synvisc-One are reported with the same HCPCS code in 2010, J7325 (Hyaluronan or derivative, Synvisc or Synvisc-One, for intraarticular injection, 1 mg). The difference between the two drugs will be in the units reported! Report Synvisc with J7325, 16 units for each of the three injections in the series. Syvnvisc-One will be reported with J7325, 48 units one time only, as this is a single series injection. Joint Injections with Fluoro Guidance March 4, 2010
I am a foot and ankle orthopaedist, and I perform ankle joint injections and subtalar injections in the office using fluoroscopic guidance. My question is: Do I report CPT code 76000 or 77002 to report the fluoroscopic guidance. This is not an uncommon question. The correct code is 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device). If you own/lease the equipment you will report 77002 as a global CPT code. Remember to dictate a separate report to support the professional interpretation component of the fluoroscopic guidance. Remember to document the medical necessity of why the injection required fluoroscopic guidance. Is Insertion of a Drain Reportable? February 18, 2010 Our surgeon recently performed a debridement and repair of a knee wound. The surgeon made a separate incision and placed a JP drain before the final closure. I cannot find a CPT code for the insertion of this drain. Is this a separately reportable service? No, the insertion of the drain at the surgical site is considered to be an integral part of the procedure and thus not separately reportable. Interposition arthroplasty: Trapezium, trapezoid, are they included? February 4, 2010 Our surgeon performed and documented an interposition arthroplasty. In reviewing the operative note, the surgeon documented the excision of the trapezium and the trapezoid bone. Is this work separately reportable with the CPT code for the interposition arthroplasty? If we look at the AAOS Global Service Data Guide or Code-X, we see that the inclusions list for the interposition arthroplasty states partial or total excision of trapezium or trapezoid. If the surgeon removes the trapezium only, which is the most common bone removed, then this work is included and not separately reportable. If the surgeon documents excision of both the trapezium and the trapezoid bones, CPT code 25210-59 (Carpectomy; one bone) may be reported in addition to CPT code 25447. Bilateral Anterior Cervical Discectomy/Decompression January 21, 2010 Can we bill 63075 with modifier 50 (bilateral procedure) when the surgeon documents decompression of both sides of the spine? It would not be appropriate to append modifier 50 to CPT 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace). This code says decompression of the nerve root(s) implying that one or both nerve roots would be decompressed during the procedure; therefore, modifier 50 could not be appended to 63075. Pelvic Ring Fractures January 7, 2010
We submitted CPT code 27217, Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami) to Medicare and received a denial that this CPT code is an invalid code. Have you heard anything about this? Yes, unfortunately, when CPT added the 2009 guideline instructions that this procedure code could be reported bilaterally, Medicare disagreed with this and created their own G codes. For Medicare only, you would report G0414 Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation when performed (includes pubic symphysis and/or superior/inferior rami). Note in the Medicare G code description, they added the terms unilateral or bilateral meaning they will not recognize this as a bilateral procedure and will pay 25.75 RVUs one time only. Remember the G code applies to Medicare only.