Orthopedic Coding Alert

CMS doesn't agree with this revision, so here's what you will have to report instead. If you struggle for reimbursement when your physician repairs both sides of a pelvis, CPT 2009 brings welcome relief -- at least, when you submit claims to private payers. To keep denials from hitting your desk, you must delineate what pelvic fracture repair codes to use for private payers and Medicare carriers. You Might Succeed in Extra Payment from Private Payers CPT 2009 revises the descriptors to pelvic fracture treatment codes (27215-27218) to specify these procedures are "unilateral." This means you can append modifier 50 (Bilateral procedure) in cases when your physician is repairing both sides of the pelvis and expect 150-percent reimbursement. Here are the new definitions (emphasis added): - 27215 -- Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed - 27216 -- Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum) - 27217 -- Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami) - 27218 -- Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum). Translation: Suppose your orthopedist performs the work represented by 27218 on both sides of a patient's pelvis. This means you can apply modifier 50 to 27218. Calculate: Currently, the work relative value units (RVUs) for 27218 are 20.93. In 2008, Medicare automatically applies a budget neutrality adjustor (BNA) to the work RVUs of a procedure, which in this case will lower the work RVUs for 27218 to 18.43 (20.93 x 0.8806 BNA = 18.43, rounded to two decimal places). Adding the adjusted work RVUs to the physician expense (PE) RVUs and the malpractice RVUs for 27218 yields a total of 33.29 RVUs (18.43 work RVUs + 11.37 PE RVUs + 3.49 malpractice RVUs = 33.29 total RVUs). Multiply the total RVUs by the 2008 conversion factor (38.087) to arrive at the fee: $1267.92 (unadjusted for geography). In 2009, CMS will apply the BNA to the conversion factor, not just to the work RVUs. Take the total 2009 RVUs for 27218 (20.93 work RVUs + 11.68 PE RVUs + 3.49 malpractice RVUs = 36.10 total RVUs) and multiply them by the 2009 conversion factor, 36.0666, to calculate your reimbursement: $1302.00. This is a $34 increase from the 2008 reimbursement ($1302.00 - $1267.92 = $34.08). [...]