Orthopedic Coding Alert

Start with 29888, but check global package and add-ons for your most complete claim.

With football season in full swing, your orthopedic surgeon will probably treat some weekend warrior injuries — especially for Anterior Cruciate Ligament (ACL) damage.

Good news: “I find ACL reconstructions fairly straightforward to code,” says Sandi Hamrick, CPC, medical/surgical coder at Toledo Orthopaedic Surgeons in Toledo, Ohio. “Make sure the op note is carefully read, so you don’t miss coding for any meniscus procedures that the physician may also perform.”

Read on to learn the difference between revision and reconstruction — and what services you might be able to report separately— to score your best coding every time.

Repair or Reconstruction = 29888

When your physician treats an ACL injury, he has two options: repair the ligament, or reconstruct it. The CPT^® code for either procedure is 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction).

Most physicians do not perform repairs. “We reconstruct, which means using other tissue to replace the ACL,” says Carol Wilson, CPC, in Leesburg Orthopedics in Leesburg, Va.

Heads up: “As far as using an ACL with a graft, you should include the harvesting and fixating of the graft with the ACL procedure you’re reporting,” Wilson adds.

Caution: Debridement of torn fibers does not equal ACL reconstruction or repair. If your physician focuses on debridement, report 29999 (Unlisted procedure, arthroscopy) instead.

Complications Could Mean 22

ACL procedures can be more complex than what 29888 describes. For example, your surgeon may have to remove the hardware that another surgeon left in place, take out a previously placed tendon graft, and revise tibial and/or femoral tunnels. Scar tissue also might make surgical dissection more complicated. Keep these things in mind when coding more involved cases:

• If your surgeon documents spending extra time on the case, you might be able to append modifier 22 (Increased procedural services). The use of modifier 22 would only be appropriate if there was extensive scarring or documented increased complexity, experts say. This is not commonly the case for a primary repair and is more appropriate in revision ACL procedures.
• Indicate any extra time revision surgery involves compared to standard ACL reconstruction. An ACL repair often takes about an hour to one hour and 15 minutes to complete, while revision procedure can add 20 to 30 minutes, depending on the findings, physicians report.
• You should report 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) for removal of hardware (i.e., screw) placed by another surgeon when performing a revision ACL reconstruction.

Revision red flag: Your orthopedist might sometimes remove metal hardware before he can proceed with another procedure. Don’t automatically submit a code such as 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]), however, because CPT^® guidelines prohibit reporting 29888 with a hardware removal code.

You can report a revision ACL procedure using 29888-22 or 29999. Explain why the procedure was more complex and how the revision differed from the initial repair or reconstruction.

Diagnoses: Be careful to report Z47.2 (Encounter for removal of internal fixation device) or T84.116A (Breakdown [mechanical] of internal fixation device of bone of right lower leg, initial encounter)-T84.117A (… left lower leg, initial encounter) to the diagnosis code for the procedure to support the presence and removal of prior hardware. Also code any bony deficit (M89.761, Major osseous defect, right lower leg or M89.762, … left lower leg), adhesions (M24.661, Ankylosis, right knee or M24.662, … left knee), or other anatomical changes that lead to increased complexity and support your claim for increased reimbursement.

Menisectomy Is Legit Add-On

Although the ACL global package is fairly comprehensive, you can sometimes report additional services. For instance, menisectomy (29880/29881) and meniscal repair (29882/29883) may always be reported in addition to code 29888.

You can also report knee arthroscopy codes 29879-29883 in addition to the ACL procedure, according to the AAOS.

For starters, follow these three tips:

• Watch locations. AMA guidelines state that the phy­sician must perform chondroplasty or loose body removal in a different knee compartment before you can report separate codes.
• Double-check coding edits. Codes inclusive with Correct Coding Initiative (CCI) modifier “0” are: 29874, 29877. Codes inclusive with CCI modifier “1” are: 29870, 29871, 29875, 29876, 29884. Translation: Expect these bundles if your payer requires you to apply CCI guidelines to your claims.

Arthroscopy example: Your orthopedist performs an arthroscopic-aided ACL repair and performs medial meniscus repair and partial lateral meniscectomy. Taking the previous tips into consideration, Hamrick suggests you should report:

• 29888 for the ACL repair
• 29882-51 (... with meniscus repair [medial OR lateral]; Multiple procedures) for the medial meniscus repair
• 29881 (... with meniscectomy [medial OR lateral, including any meniscal shaving] including debridement/shaving of articular cartilage (chondro­plasty), same or separate compartment[s], when performed) for the partial lateral meniscectomy.

Remember, report modifier 51 only to those payers who accept it. And if the payer requires you to follow CCI guidelines, append modifier 59 (Distinct procedural service) to override the mutually exclusive edit for 29881 and 29882. When deciding which code to append modifier 59 to, follow your payer’s preference.