Orthopedic Coding Alert

CPT 2002 includes several new musculoskeletal codes that the Correct Coding Initiative (CCI) has yet to address, especially with regard to the appropriateness of bundling some of these procedures. Although many billers rely on CCI's quarterly edits for the most current Medicare bundling guidance, non-Medicare carriers can bundle according to any guidance that professional societies and associations offer.

The American Academy of Orthopaedic Surgeons (AAOS) recently published Global Service Data 2002, a guide that physicians and coders will find useful particularly in the absence of any CCI edits on the use of new musculoskeletal codes appearing in CPT 2002. Global Service Data 2002 lists every surgical code from the Musculoskeletal section of CPT, as well as the services included in each code's global package. The guide also includes bundling rules for these codes.

Note: CCI did not include edits on the use of new musculoskeletal codes in its latest version (CCI version 8.1, effective April 1-June 30, 2002); thus, the earliest date that CCI could implement any edits involving these codes is July 2002.

Although carriers are not required to adhere to AAOS bundling principles, the policies of several carriers follow large portions of the bundles. Besides CMS, the AAOS is what I use for appeals for many bundling issues," says Christie Beach, CPC, of Comprehensive Orthopedics in Kenosha, Wis. "The guide is backed by orthopedic physicians who understand the full scope of procedures and what is really incidental and what is not."

The AAOS guide not only provides authoritative direction as to what procedures should and should not be billed separately but also may serve, at least in part, as the basis for any future CCI edits to codes covering these procedures. And while non-Medicare carriers have the option of following CCI and/or AAOS edits, the AAOS sets the standard for reasonable inclusions and exclusions of these new codes.

"Each carrier has its own proprietary bundling policies, code edits, etc.," says Heidi Stout, CPC, CCS-P, coding and reimbursement specialist at University Orthopaedic Associates in New Brunswick, N.J. "Global Service Data 2002 is an important tool in determining how to correctly report surgeries that may involve multiple CPT codes and gives you compelling backup in instances when the carrier inappropriately rebundles codes."

Shoulder Codes

Shoulder arthroscopy codes 29806, 29807 and 29824 were a welcome addition to CPT 2002. Prior to the creation of these codes, orthopedists often resorted to unlisted-procedure codes when billing shoulder arthro-scopies. Cumbersome documentation usually included a KISS letter, an operative report and an analogous code, with an explanation of the analogous code's relationship to the procedure performed.

While the addition of three new shoulder arthroscopy codes is not an overnight solution to billing woes, it definitely improves the coding and reimbursement landscape for shoulder surgery.

All three of these procedures include shoulder arthroscopy codes 29805, 29820, 29822 and 29825.

Code 29806 also includes capsulorrhaphy codes 23450, 23455, 23460, 23462 and 23465; shoulder dislocation treatment codes 23650, 23655 and 23660; and shoulder joint manipulation code 23700*.

The AAOS indicates that 29806 also includes thermal capsular shrinkage, the procedure that uses thermal energy to reduce stretched tissue to its normal size and increase shoulder stability. When performed alone, thermal shrinkage is reported as 29999 (Unlisted procedure, arthroscopy).

"The bundling of the thermal capsular shrinkage is a little surprising," Stout says. "My surgeons routinely charge for these separate from the arthroscopic capsulorrhaphy."

Since the thermal shrinkage uses different instruments, the bundle is a little unusual, but the AAOS has determined that no additional code should be reported if an arthroscopic Bankart (29806) and thermal shrinkage are done together.

Otherwise, the edits follow the pattern of their open-procedure counterparts (e.g., 23455, Capsulorrhaphy, anterior; with labral repair [e.g., Bankart procedure]), including reduction of shoulder dislocations and manipulation of the shoulder joint as well as the open capsulorrhaphy codes. AAOS also bundles all of the codes for open capsulorrhaphies so it is understood that an open and arthroscopic repair should not be reported together. Note that 29807 does not include any open repair codes because there is no code for open repair of a SLAP (superior labrum, anterior to posterior) lesion.

Code 29807 also includes 23700*.

Code 29824 also includes arthrotomy codes 23044 and 23101, as well as claviculectomy code 23120.

Wrist Codes

Several new codes for treating disorders of the wrist resulted in numerous coding bundles.

Code 25671 (Percutaneous skeletal fixation of distal radioulnar dislocation) includes 25675 (Closed treatment of distal radioulnar dislocation with manipulation).

Code 25652 (Open treatment of ulnar styloid fracture) includes:

These code edits follow the same pattern as other open reduction with internal fixation codes in the wrist section, including wrist arthrotomy and synovectomy/tenosynovec-tomy codes.

In addition to 25105 and 25118, 25431 (Repair of nonunion of carpal bone [excluding carpal scaphoid (navicular)] [includes obtaining graft and necessary fixation], each bone) includes:

The bundles for these new wrist procedures are in keeping with existing edits for repair of carpal scaphoid nonunion (25440, Repair of nonunion, scaphoid carpal [navicular] bone, with or without radial styloidectomy [includes obtaining graft and necessary fixation]), except for addition of the capsulotomy code.

Code 25394 (Osteoplasty, carpal bone, shortening) includes 25115; 25116; 25118; 25295 (Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon); neuroplasty codes 64704, 64708, 64719 and 64721; and 64722 (Decompression; unspecified nerve[s][specify]). These edits are consistent with those for osteoplasty, radius or ulna (25390), with the inclusion of tenosynovectomy/tenolysis/neurolysis codes.

Code 25275 (Repair, tendon sheath, extensor, forearm and/or wrist, with free graft [includes obtaining graft] [e.g., for extensor carpi ulnaris subluxation]) includes 25000 (Incision, extensor tendon sheath, wrist [e.g., deQuervains disease]), 25118, 25295, 64704, 64708 and 64719.

Codes 25024 (Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve) and 25025 ( with debridement of nonviable muscle and/or nerve) include codes for removal of a foreign body in muscle or a tendon sheath (20520* and 20525), 25020 (Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve) and 25248 (Exploration with removal of deep foreign body, forearm or wrist).

Code 25025 also includes 25000, 25024, 64719 and 64721.

Elbow Codes

Four new codes were introduced for elbow ligament repair or reconstruction: 24343, 24344, 24345 and 24346.

All of these codes include arthrotomy codes 24000, 24006, 24100, 24101 and 24102; 24341 (Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary [excludes rotator cuff]); and fasciotomy codes 24350, 24351, 24352, 24354 and 24356. Codes 24345 and 24346 also include 64708.

Code 24332 (Tenolysis, triceps)includes 24105 (Excision, olecranon bursa), 24350-24356, 64708 and 64718 (Neuroplasty and/or transposition; ulnar nerve at elbow).