Orthopedic Coding Alert

Case Description

The patient is a 50-year-old female with symptomatic osteochondral defect of the medial femoral condyle. The orthopedist recommends surgery to restore function and reduce pain. Traditional surgery to repair such damaged articular cartilage involves scraping the area to induce bleeding, which then fills in the damaged area.

But a new procedure called MosaicPlasty, or osteochondral allograft transfer (OATS), takes healthy cartilage plugs from the donor site (peripheral or non-weight-bearing areas of the knee) and transfers them into the prepared damaged area (recipient site). Usually MosaicPlasty is done under arthroscopic guidance, but it can also be done as an open procedure based on surgeon preference and the location and extent of the chondral defect and harvest site.

Operative Report

Three arthroscopy portals were established to include superior medial inflow and medial and lateral working joint line portals. Inspection of the joint revealed 9 x 20 mm medial femoral chondylar full-thickness chondral defect with osteochondral loose bodies located intra-articularly.

Using meniscal graspers, loose bodies of multiple osteochondral fragment, including several large fragments, were removed from the joint without difficulty. The defect having been measured, the rim was cleaned with a currette. The size was defined and the determination was made to proceed with the OATS procedure rather than the Genzyme Carticel biopsy.

An 8 mm size was chosen and a series of two plugs were performed. The vicinity of the sulcus terminale of the lateral femoral condyle was utilized for donors. A series of two plugs were harvested. A donor graft was harvested first; the recipient graft was measured and harvested to match. Sequential implantation of the plug was performed without difficulty. The plugs were noted to restore congruity of the joint surface appropriately.

Having thus completed the osteochondral plug transfer, copious irrigation of the joint was performed and close was performed. It should be noted that two accessory medial portals were utilized to optimize angular approach to the medial femoral condylar region.

Coding Dilemma

With OATS, as in many other orthopedic procedures, technology has outpaced development of CPT codes: None describe this new procedure precisely.

But in trying to find a code that best describes the procedures, orthopedists, who are often misinformed by sales reps, may be upcoding, experts warn.

For example, for a MosaicPlasty with eight plugs, one physician believed he could bill 27442 (arthroplasty, femoral condyles or tibial plateaus, knee) as well as charge eight times for 29885 (arthroscopic OCD drilling with/without internal fixation).

Such logic leads to upcoding, warn our coding experts.

The American Medical Association (AMA) also states chondroplasty of the knee (29877) should not be reported separately because its considered part of the overall procedure. Likewise, it would be inappropriate to bill any of the following codes for MosaicPlasty:

20900 bone graft

20902 bone graft large

29877 arthroscopic chondroplasty

29879 arthroscopic abrasion

Note: OATS also can be performed as an open procedure, so check the operative notes carefully. If this is the case, do not bill the unlisted scope code. Instead, use 27599 (unlisted procedure, femur or knee).

Coding Solution

The only available option is to follow the advice given in the July 1998 issue of CPT Assistant: Use 29909 (unlisted procedure, arthroscopy).

The guidelines for coding endoscopic procedures state that codes for open surgical procedures should not be used to report a procedure using an endoscopic approach, and that if no code exists for the endoscopic procedure, you have to use an unlisted code.

Although many coders are afraid to use the unlisted code because they heard it means minimal reimbursement, in many cases thats your only choice, especially where cutting-edge technology is concerned.

There is this unfounded fear of billing any code ending with -99 (unlisted codes), so many coders tend to make do with a code they feel is close enough. But often the result of this approach is upcoding at worse and inappropriate at best, warns Susan Callaway-Stradley, CPC, CCS-P, winner of the American Academy of Professional Coderss 1998 Coder of the Year Award and senior consultant for Medical Group of Elliott, Davis and Co., LLP, in Augusta, GA.

Callaway-Stradley explains that if the claim is supported by excellent documentation and a well-written cover letter, the unlisted code may be more appropriate than using a current code that does not represent the innovative procedure.

Rebekah Bailey, CPC, agrees. You must select the code that best represents the procedure and, in this case, it is 29909, says the coding/documentation training specialist at the reimbursement office at the University of South Alabama in Mobile. Callaway-Stradley and Bailey offer these tips to receiving the highest reimbursement you are ethically entitled:

1. Prepare an outstanding op report. Describe every step in as much detail as possible. Do not assume knowledge on the part of the payer.

2. Submit a KISS letter. This Keep It Short and Simple is a summary letter of no more than three or four sentences, in laymens terms, that explains why you are billing the unlisted code and what reimbursement you are requesting. In the case of an OATS procedure, you might write, We are submitting this operative report for an osteochondral allograft transfer, called OATSa procedure that currently has no adequate CPT description. The code most similar to this in terms of relative value units is 29885 (arthroscopic OCD drilling with/without internal fixation) which pays $___. Please consider a total fee of $___.

Note: The additional reimbursement is usually 20 to 30 percent above the comparative procedure.

3. Explain the procedure is not experimental. If payers deny on these grounds, appeal by writing directly to the medical director. Talk with the manufacturer to gather statistics and references: The procedures proven track record, number of cases performed, including patient outcomes, success and failure rates over the long term. Show payers how the OATS procedure compares favorably in cost and patient outcomes to traditional methods. Include citations from medical journals.

They want facts and figures, stresses Bailey.

Terminology Allograft living tissue Osteochondral defect an imperfection pertaining to a bone and its cartilage Medial femoral condyle one of two flat, oval-shaped articulating surfaces in the femorotibial joint that allows for rotation in the knee Articular cartilage the covering of the ends of the bones. Helps to protect the joint by allowing the bones to slide freely on each other v