Coding Knee Arthroscopy with Precision

Coding Knee Arthroscopy with Precision

A clear understanding of CPT® and Medicare guidelines will put your claims for these procedures on solid ground.

Although knee arthroscopy is common, coding these surgical procedures can be complicated. Payment for knee arthroscopy hinges on proper coding, and proper coding relies on your knowledge of the code definitions and the differences between CPT® and Medicare guidelines. This article addresses both Medicare and private payer coding and guidelines for knee arthroscopy.

Determine Which Guidelines to Follow

The first thing to ask is whether the procedure is diagnostic or therapeutic. Diagnostic arthroscopies are used to examine and diagnose problems in the knee joint; surgical arthroscopies are used to treat diseased or damaged areas such as torn menisci, chondromalacia, or inflamed synovium.

Know Your Knee Anatomy

Three compartments comprise the knee: medial, lateral, and patellofemoral. The medial compartment includes the medial femoral condyle, medial tibial plateau, and medial meniscus. The lateral compartment consists of the lateral femoral condyle, lateral tibial plateau, and lateral meniscus. And the patellofemoral compartment includes the patella, patellofemoral joint, intercondylar femoral notch, suprapatellar pouch, and the trochlea.

The meniscus is a c-shaped piece of cartilage between the tibia and femur, which absorbs shock, provides a cushion between the bones, and keeps the knee stable. There are two menisci in each knee joint.

Meniscectomy

Torn meniscus is a common diagnosis. Sudden or direct pressure to the knee, as well as forced rotation, deep squatting, or heavy lifting, can lead to meniscus injuries. Degeneration and overuse can weaken the cartilage, making the menisci prone to tears.

Treatment for meniscus damage depends on the size, type, and location of the tear. Most surgeons treat meniscus tears with arthroscopic surgery, which involves inserting a thin, flexible fiber-optic device into a small incision in the knee. The surgeon then maneuvers tools through the arthroscope or additional incisions in the knee.

Meniscectomy codes include:

29880  Arthroscopy, knee, surgical with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

29881  Arthroscopy, knee, surgical with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

During a meniscectomy, the surgeon removes a piece of the torn meniscus or the entire meniscus. CPT® code 29880 reports a meniscectomy in both the medial and lateral compartments, while CPT® code 29881 indicates a meniscectomy in either the medial or lateral compartment. Both codes include debridement/shaving of articular cartilage (chondroplasty), in the same compartment or separate compartments of the same knee.

CPT® codes for meniscus repair without chondroplasty include:

29882 Arthroscopy, knee, surgical with meniscus repair (medial OR lateral)

29883  Arthroscopy, knee, surgical with meniscus repair (medial AND lateral)

For meniscus repair, the surgeon repairs the torn part of the cartilage with dart- or arrow-shaped devices, which are absorbed by the body over time. CPT® code 29883 reports a meniscus repair in both the medial and lateral compartments, while CPT® code 29882 reports a meniscus repair in either the medial or lateral compartment. Chondroplasty may be separately reported when performed in a separate compartment of the same knee as the meniscus repair.

Chondroplasty

Although the National Correct Coding Initiative (NCCI) bundles 29877 Arthroscopy, knee, surgical debridement/shaving of articular cartilage (chondroplasty) and the meniscal repair codes, with a “0” modifier indicator, which typically means you cannot separately report the codes under any circumstance, Medicare allows providers to separately report chondroplasty with meniscal repairs if performed in a different compartment of the same knee. Medicare instructs coders to use HCPCS Level II 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. Do not separately report chondroplasty if another surgery is performed in the same compartment.

Because the definition for G0289 says, “at the time of other surgical knee arthroscopy,” if chondroplasty is the only procedure performed, 29877 is the appropriate code for all payers, including Medicare.

Arthroscopy codes 29877 and G0289 may never be reported with meniscectomy codes 29880 or 29881 for the same knee because the chondroplasty is inclusive to their definitions.

Capture Loose or Foreign Body Removal

As is true when reporting chondroplasty, CPT® and Medicare have different reporting requirements to report arthroscopic removal of loose or foreign bodies.

The Global Service Data (GSD) guidelines clarify that reporting arthroscopic removal of loose or foreign bodies is included in the base procedure, but the removal of loose or foreign bodies greater than 5 mm and/or through a separate incision is separately reportable. Under these criteria, for a non-Medicare patient, a physician would report loose or foreign body removal using CPT® 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) with a primary service such as meniscectomy or meniscal repair (even from within the same compartment), with modifier 59 Distinct procedural service to indicate the size or separate incision criteria are met.

For Medicare patients, however, G0289 specifies that the loose or foreign body removal must be performed “in a different compartment of the same knee.” Therefore, for a Medicare beneficiary, do not report loose or foreign body removal performed in the same compartment as another procedure, even if the size or incision criteria are met. Report 29874 for a Medicare patient only when it’s the only procedure performed.

Medicare reinforces its definition of G0289 in Chapter IV of the NCCI guidelines: “HCPCS code G0289 shall not be reported for removal of a loose body or foreign body or debridement/shaving of articular cartilage from the same compartment as another knee arthroscopic procedure.”

Differentiate Limited vs. Major Synovectomy

CPT® has assigned the “separate procedure” designation to 29875 Arthroscopy, knee, surgical synovectomy, limited (eg, plica or shelf resection) (separate procedure). As such, do not report 29875 with other arthroscopic procedures in the same knee. You may only report 29875 when it’s the only arthroscopic procedure performed on the knee. Compartments are not recognized for the purpose of reporting this code.

To report 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral), the documentation must establish pathologic synovial disease is present, not merely loose synovium in the joint. The surgeon should document the medical necessity and performance of synovial resection from two or more compartments in the knee. Reporting major synovectomies also varies between CPT® and Medicare rules.

According to CPT®, as long as pathologic synovial disease is present, you may use 29876 with another arthroscopic knee procedure, even if it occurs in the same compartment — excluding procedures for removal of loose/foreign body or chondroplasty.

Medicare, however, dictates through an NCCI guideline in Chapter IV that 29876 is reported only if no other arthroscopic surgery is performed in the same compartment. The guideline states, “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.”

En Pointe

Coding knee arthroscopies is far less complicated when you are clear on which guidelines to follow and understand what the guidelines mean. Always thoroughly review the provider’s documentation in the medical record and ask questions if you’re missing a piece of information necessary to code correctly.

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Carol Ermis
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Carol Ermis, CPC, COSC, CPMA, AAPC Fellow, is the billing director at Orthopaedic Specialists of Austin, where she’s managed the revenue cycle for 13 years. She serves on the advisory board for The College of Health Care Professions. Ermis is a member of the Austin, Texas, local chapter.

2 Responses to “Coding Knee Arthroscopy with Precision”

  1. Lindsay C says:

    Your article states 29876 as long as pathologic synovial disease…do you mean PVNS? Thanks, Lindsay

  2. Lee Fifield says:

    Lindsay, the author did not mean PVNS instead of pathologic synovial disease. PVNS is indeed a type of pathologic synovial disease as “Synovial diseases can be classified as inflammatory, infectious, degenerative, traumatic, hemorrhagic, and neoplastic. Damage in other intraarticular structures, particularly cartilages, generally occurs as a part of pathologic processes involving the synovium, leading to irreversible joint destruction,” according to the NIH. PVNS does fall under inflammatory disease. So, the code should apply based on these definitions.

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