Avoid SLAP and Bankart Repair Denials:
Don't Substitute Codes
Published on Fri Oct 01, 1999
A photographic record could be your answer to the nagging problem of receiving reimbursement for arthroscopic shoulder stabilization procedures. This is because these procedures have only unlisted codes that apply, and the visual evidence may be the only way to get paid.
Arthroscopic surgeons are frustrated with the current codes, says William Levine, MD, an orthopedic surgeon and the director of sports medicine at Columbia Presbyterian Hospital, NY. Levines coders use 29909 (unlisted procedure, arthroscopy) for SLAP repair (repair of the proximal biceps tendon) and Bankart repair (repair of the glenoid labrum). And as for documentation, Levine explains, I take photographs of every procedure. That way, when Levines coders are fighting battles with insurers, they have an actual picture to submit.
Note: One orthopedic expert recommends keeping the photos on file for seven years.
Many surgeons are adding photos to their documentation when they perform arthroscopic procedures, one reason being that its so easy to add a camera to the set-up. Orthopedists need to take time up front to document precisely, including the surgical notes and the diagnosis to support medical necessity in order to get reimbursed for procedures that have an unlisted or unspecified code assigned.
Open Code is Not a Substitute
Code 23455 (capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation, with labral repair [e.g., Bankart procedure]) is for shoulder stabilization, but it applies only to open procedures. Still, that code can be useful for comparative purposes, according to Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, SC.
The important thing is not to tweak the code. You are inviting trouble, says Callaway-Stradley. Open procedure codes, such as 23455, should only be used when open procedures are performed. When a certain type of procedure category, such as arthroscopies, does not provide an adequate CPT code, it is not appropriate to pick the closest open procedure as a substitute. Not only does that contradict the basic premise of CPT coding but typically open procedures have higher values than their scope counterparts.
Although the editorial panel of the American Medical Association (AMA) charged with CPT code oversight can add a code, third-party payers assign a dollar value to each one. In the interim, comparisons with open procedures can help coders inform insurers that they are getting good value, whatever price they settle on for the unlisted procedures.
For example, in a 1998 study comparing open and arthroscopic Bankart procedures, F. Alan Barber, MD, of the Plano Orthopedic and Sports Medicine Center, Plano, TX, found total fees (including anesthesia and facility) were nearly 22 percent less for the arthroscopic than for the open procedure: Thats $4,474 compared with $6,062.
Documentation is as Crucial as Ever
Beyond the [...]
