Orthopedic Coding Alert

Find out how the ortho coding world is responding to 2021 CPT^® changes.

A lot happened in the coding world in 2021; change was everywhere, resulting in quite a bit of new information for coders to digest and work into their everyday coding routines.

How’s it been going overall? That’s the question Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, attempted to answer during her presentation “Orthopedic Surgery Coding: Present and Future” at HEALTHCON Regional 2021 in Charleston, South Carolina.

The purpose of her presentation was to go over “all of these things we’re dealing with in ortho coding at the moment. … and some 2022 changes as well as some 2023 changes,” explained Anderanin, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. Here’s what she had to say.

The Present: Shoulder Arthroscopy

Looking back at what changed this year, Anderanin expressed her frustration at the lack of acceptance for codes 29822 (Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])) and 29823 (… debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])).

The more detailed descriptor language in 29822 and 29823 was supposed to make it easier to get these codes paid in 2021; that hasn’t happened yet, Anderanin lamented.

“No matter what we do, no matter what CMS [Centers for Medicare and Medicaid Services] and CPT^® do, this is a nightmare for us. The 29822 never gets paid with anything else, and with 29823 it still doesn’t seem to be working,” she explained.

“We keep working with doctors to get them to give us the documentation we need to report these codes. The thing I tell them is don’t try to bill for debridement of something that you then go and fix.” But if you’re debriding separate things, document them using this list of separate structures:

• Humeral bone or humeral articular cartilage
• Glenoid bone or glenoid articular cartilage
• Biceps tendon or biceps anchor complex
• Labrum
• Articular capsule
• Articular or bursal side of the rotator cuff
• Subacromial bursa
• Foreign body(ies).

One area that Anderanin said coders are having more success is with these codes, which had their rules tweaked in 2021:

• 29819 (Arthroscopy, shoulder, surgical; with removal of loose body or foreign body)
• 29834 (Arthroscopy, elbow, surgical; with removal of loose body or foreign body)
• 29861 (Arthroscopy, hip, surgical; with removal of loose body or foreign body)
• 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation))
• 29894 (Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body)
• 29904 (Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body).

The basics: “This was not a coding change, it was more of a guideline change,” explained Anderanin. The change states that the diameter of the cannula must be the same size or bigger than the diameter of the arthroscopic cannula used for a specific procedure by:

• Larger cannula,
• Separate incision, or
• Enlarged portal.

The Present: Mid-Year T Code Additions

Effective July 1, 2021, there was a pair of new T codes to add to your CPT^® list:

• 0656T (Vertebral body tethering, anterior; up to 7 vertebral segments)
• 0657T (Vertebral body tethering, anterior; 8 or more vertebral segments)

As these codes are so new they aren’t even on the books for 2021, contact your payer and talk to your provider before you even consider reporting them.

If you decide to use them, CPT^® instructs you not to report 0656T or 0657T in conjunction with:

• 22800 (Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments)
• 22802 (… 7 to 12 vertebral segments)
• 22804 (… 13 or more vertebral segments)
• 22808 (Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments)
• 22810 (… 4 to 7 vertebral segments)
• 22812 (… 8 or more vertebral segments)
• 22818 (Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments)
• 22819 (… 3 or more segments)
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure))
• 22846 (… 4 to 7 vertebral segments (List separately in addition to code for primary procedure))
• 22847 (… 8 or more vertebral segments (List separately in addition to code for primary procedure)).

The Present: NCCI Update on Biomechanical Devices

According to the CMS National Correct Coding Initiative (NCCI) Policy Manual 2021, there is a significant development that will lend ortho coders clarity on a touchy biomechanical devices/instrumentation question.

This NCCI edit deals with “another problem that we continue to have related to spine surgery: and the billing of instrumentation and cages in the same place,” said Anderanin.

The ruling involves the following codes:

• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure))
• +22854 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure))
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure))
• +22846 (… 4 to 7 vertebral segments (List separately in addition to code for primary procedure))
• +22847 (… 8 or more vertebral segments (List separately in addition to code for primary procedure)).

According to the NCCI policy manual, CPT^® codes 22853 and 22854 describe insertion of interbody biomechanical device(s) into the intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT^® codes (e.g., 22845-22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59 or XU.

Takeaway: “This means that if you’re using instrumentation that is not used for anchoring of a cage, it’s a separate component,” explained Anderanin. Physicians can use this as a base for describing this difference in their documentation if they need to use this NCCI edit.

However: “If they are not separate things, if the cage is part of the instrumentation, then we cannot bill it separately,” she said.

CPT^® reports that you can use +22853 or +22854 with the following codes:22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307.

The Present: Office/Outpatient E/Ms

As everyone who codes knows, CPT^® made the most major 2021 changes on office/outpatient evaluation and management (E/M) services. When choosing a code from 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.), you can use time or medical decision making (MDM) as the deciding factor.

This has created a need for coders to reexamine their MDM and time coding, as they’re the only components you can rely on to make an informed decision on the 99202-99215 codes.

When counting up time on an office/outpatient E/M code, Anderanin says you should ask yourself the following questions before filing:

• “Is everything being counted?”
• “Does the documentation support the visit?”
• “Are the appointment schedules proportionate to the visits?”
• “How often are you using 99417 [Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)] and G2211 [Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)]?”

As for office/outpatient E/Ms that you code based on MDM, Anderanin says you should make sure that the practice has:

• Updated templates that reflect the new code descriptors.
• Policies in place on how the practice addresses MDM questions and how it interprets risk.
• Buy-in from all your providers on the new E/M rules; coding will suffer — and auditors will notice — if you’re coding for providers you can’t convince to use the time/ MDM rules.
• Safeguards in place against the elimination of encounter data that might be used to prove MDM.