Orthopedic Coding Alert

RVU decreases by 14.24 but remains higher than the 50% multiple procedure reduction.

Now that CPT® code +29826 is an add-on code, you've changed the way you're reporting your surgeon's subacromial decompression services. Read on for an update on how the status change to +29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e. arch] release, when performed [List separately in addition to code for primary procedure]) may affect your reimbursement this year.

"The new RVU for 29826 is 5.24, compared to the old RVU of 19.48, a decrease of 14.24 RVUs," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington.

The bottom line: Last year's payment was an average of $ 662 (RVU 19.48 x 33. 9764), whereas in 2012, you'll receive $ 178.3 (RVU 5.24 x 34.0376) depending on payer variations.

Sort Out the Modifier 51 Factor

Old way: Before 29826 acquired an add-on status in 2012, you reported as a second or third CPT® code on a claim, along with some other CPT® code for procedures such an extensive debridement that your surgeon does. Appending modifier 51 (Multiple procedures) to 29826 would reduce payment by 50 percent for the second position code and 25 percent for third position.

New way: Now that 29826 has add-on status, you can no longer append modifier 51, so the code would be paid at its current RVU value (5.24).

Silver lining: The good news is that the impact is not as huge when the procedure is done with the other arthroscopic shoulder procedures. "It is not that big a loss. First of all, if the private payers used the 50 percent, 25 percent rule, then the old code was only worth either 9.74 RVUs (50 percent) or 4.87 (25 percent), which was actually less than the 5.24 now allowed. If the Medis rule is used in which the second arthroscopy code RVU is subtracted from the base RVU of 29805 (diagnostic only), there is almost no difference," explains Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

"For Medicare, the RVU loss is 0.56 comparing the fourth quarter 2011 to first quarter 2012. The greater loss will be reflected in reporting code 29822 instead of 29826 when the procedure is performed as a standalone and for payers that use the 100/50 MRSP methodology," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

"In 2011, CPT® code 29826 had 19.48 RVUs, while the 2012 RVUs for code 29822 are 16.92, representing a reduction of 2.56 RVUs when arthroscopic subacromial decompression is performed as a standalone procedure," adds Stout.

Example: If you report 29826 with 29822 (Arthroscopy, shoulder, surgical; debridement, limited) or 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), you can see the difference in payment. There is an evident loss of RVUs. Reassessing the standalone procedure, you see that previously you could bill 29826 (RVU 19.48), but now you can bill 29822 (RVU 16.92), so you will now lose 2.56 RVUs, for this standalone procedure. You lose around $ 87, applying a conversion factor of 34.0376.

Diminished impact: "For Medicare, the change in the RVUs alone is not overly significant," says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A.  "CPT® 29827 and 29824 previously had higher RVUs than 29826, therefore 29826 would have been reduced by the scope base.  The allowable for the code combination for 29827 and 29826 or 29826 and 29824 is nearly equal to that of 2011 before the change to an add-on code.   

Remember To Check With Your Payer

All payers do not have uniform preferences. Some may not be applying the scope base rule. "Those health plans that do not follow the scope base rule will be greatly affected, as the RVU assigned to 29826 for 2012 is greater than the 50 percent multiple procedure reduction the health plans would have taken," says O'Brochta-Woodward. "The question that will remain for many is that many of the health plans base their fee schedules on the previous year's CMS RVU, which for this code would not have been based upon an add-on code.  How the health plans are going to handle this is yet to be determined.  It is advisable that all review their contracts to determine if any action would be required."

(Editor's Note: For more on +29826, see Orthopedic Coding Alert, Vol. 15, No. 4 and Vol.15, No. 5.)