Orthopedic Coding Alert

Receive proper reimbursement for unlisted procedures by providing solid documentation and by going through the process of appealing denials.

As frustrating as the process of coding and getting reimbursed for endoscopic thermal capsulorrhaphy is, the endeavor illustrates why an appeal must often be considered just another part of the coding process.

Surgical techniques and technology outpace the establishment of unique CPT codes. That means an array of problems for a coder. Unlisted codes have no assigned value. Getting a payer to value the procedure the same way a practice doeseven with a thorough operative report and a KISS letteris not easy. (KISS is the acronym for Keep It Short and Simple. In this case, a KISS letter explains as succinctly as possible the procedure performed and points to the most similar listed procedure as a guide to payment. The letter aims to justify the fee requested for the unlisted procedure. An example of a KISS letter can be seen on page 36 of the May 1999 Orthopedic Coding Alert.) Worse, some procedures are considered experimental and unproven and payers will not reimburse at all, at least not in response to the first-level submission of a claim.

Endoscopic thermal capsulorrhaphy (See box) to enhance shoulder stability is one example of a procedure without a code. And it is frustrating many coders. Some coders are so frazzled they have considered using listed codes, such as the code for open capsulorrhaphy, 23455 (capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation; with labral repair, e.g., Bankart procedure) to report the arthroscopic procedure.

Hearing that idea, Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., says emphatically, Dont do it! It is not just improper coding. It is also potential fraud.

What is the solution? Perseverance and patience are what it takes to see the way through to a reimbursement.

Appeals Work

In August 1999, Ruthe Travis, administrative assistant in the department of orthopaedics at the University of Colorado Health Center, wrote to us about problems with payment for endoscopic thermal capsulorrhaphy. We recently checked in with her, and she says, We are appealing denials. And we are getting paid on appeal.

It takes persistence, but the appeals work, says Travis.

Scenario: A 20-year-old female, a college basketball player, with secondary impingement of rotator cuff tendinitis due to laxity in the shoulder undergoes a rotator cuff rehabilitation program. But the instability continues, causing the young woman problems with overhead throws, and surgery follows.

During an operating room (OR) session, the orthopedic surgeon ascertains the patients range of motion and finds it beyond normal limits. For example, with the arm abducted 90 degrees, the patient exhibits 120 degrees of external rotation.

Examination in the OR rules out other conditions such as a Bankart lesion. Because there is some fraying of the undersurface of the rotator cuffsupraspinatus and infraspinatusit is debrided with a shaver.

Using a thermal probe, the surgeon treats the capsular tissue to induce shrinkage. Examination following treatment reveals external rotation is reduced to 90 degrees when the arm abducts.

The coder uses 29909 (unlisted procedure, arthroscopy) and 718.81 (other joint derangement, not elsewhere classified, shoulder region) and sends the claim to the insurer with a copy of the operative report. The payer rejects the entire bill, $1,900, noting it wants an established CPT code.

Fighting for Reimbursement

According to Brenda Williams in the billing office of Virginia Orthopedics and Sports Medicine in Williamsburg, her experience with payment for endoscopic thermal capsular shrinkage in the shoulder has not been good.

The insurer kicks it out every time I bill for the procedure, says Williams. I did an appeal on the second level, but I am on the third-level appeal to the medical director of the company now with more than one claim.

Williams shared an example of one of her submissions, which has now been denied at the first and second level. She had sent an operative report and a KISS letter with the 29909 code. Her documentation totaled eight pages. In her cover letter to the insurer she explained there is no CPT code for the endoscopic procedure, but that it is somewhat like 23455. She also noted it is not as demanding as 23455 and estimated it is 25 percent less difficult than 23455.

The insurers responses do not seem reasonable to Williams, who laments the way CPT codes fail to keep pace with new techniques, techniques that benefit the patient by being less invasive and encouraging speedier recoveries. Nevertheless, she is determined to appeal as frequently as she must and to get paid.

Note: As for getting prior approvals, two of the biggest insurers with whom Williams works will not pre-certify. One of them says that the thermal procedure is experimental and it will not pay.

Its Always Worth an Appeal

An appeal is exactly the way to go, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. For new procedures, an appeal is part of the process of educating insurers.

The first place to fight an insurer is before doing surgery, explains Cobuzzi. But that might not work. Still, be up front with the payer. Go and see if you can get approval. Include any literature that backs up the procedure [demonstrates its effectiveness]. Try to present a case.

And as part of the case, answer the questions the payer is likely to have. Demonstrate the new procedures worth, says Cobuzzi. What procedure did this replace? Was the patient out of work longer with the old procedure? Write up what was done before the procedure, what the heal time was, what the success rate was.

For an appeal, says Cobuzzi, I get all my guns. I get all available literature. Can you get a position paper? Can you get a member of the American Academy of Orthopedic Surgeons to write a position paper?

Cobuzzi also recommends a pragmatic approach to billing. She says, Get an advance beneficiary agreement signed by the patient, so the physician doesnt get left holding the bill.

One More Complication

Even payers that will reimburse for the endoscopic thermal capsulorrhaphy sometimes reject parts of the path a physician takes to arrive at the procedure. For example, diagnostic tests are often performed but do not give a clear picture of the patients condition. An exploratory arthroscopic procedure is still needed.

Cobuzzi sees this as another place where coders must be ready to make their case. If a diagnostic procedure is inconclusivean MRI or a CAT-scan or whatever, she says, a physician must take the next step, and that might be an arthroscope. In some cases a physician starts with a scope and must switch to open to make a diagnosis. You should not open up a patient if you dont have to.

And that is the case Cobuzzi says must be made to reluctant payers who question inconclusive diagnostic procedures. A prudent approach requires a physician to try the least disruptive route first. But if it does not yield answers, the search must continue.