Orthopedic Coding Alert

Orthopedists sometimes need to report codes for miscellaneous procedures or supplies, so coders must know what type of documentation payers want and request extra-contractual coverage to pay for these codes.

Undefined procedures are a coding challenge for any medical specialty. Carriers often deny miscellaneous codes at first sight, perhaps only to pay on appeal, if then. Yet sometimes there just isnt a well-defined code to describe the service rendered, so CPT includes a Special Services, Procedures and Reports subsection (99000-99090), which is in the Medicine Section. The codes essentially describe extra work of a clinical or non-clinical nature that goes above and beyond what is included within global service and E/M codes. If there isnt a specifically defined code for a service, look under the 990xx series for a miscellaneous services code.

CPT defines these codes as adjunct to the basic services rendered. They are used for services rendered that the practitioner feels is a legitimate charge that falls outside of global coverage, or when no global care is rendered. The following codes from the 990xx series (miscellaneous services) of CPT can be used by orthopedists in varying degrees.

99000-99002 These codes are for the handling and/or conveyance of a specimen or other item (e.g., orthotic cast) to a laboratory or other location outside the physicians office. When there is no pick-up and delivery service available, and a staff member of the orthopedic practice gets in a vehicle and goes to pick up or drop off orthotic supplies, it is a billable charge. When working with blood tests, biopsies, etc., merely putting the sample in the drop box outside the door for the lab to pick up doesnt count. An on-duty staff member must do the transporting. The code will most likely be payable for practices in rural areas, where conveyance of the specimen or supply requires a significant time commitment by the staffer.

99050-99056 These codes are for services requested after office hours, at night, or on Sundays or holidays, or at a place other than the physicians office when service is normally provided in the office. As attractive as these may look, miscellaneous services codes such as 99050 (services requested after office hours in addition to basic service) are unlikely to bring extra reimbursement, explains Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. For instance, with emergency services, these will be recognized only if the physician had to drop everything to treat the patient and it completely disrupted the practice, Callaway says. Coding for after hours, overnight and off-location services might be useful over the long term, if the physician wants to illustrate the real cost of services to third-party payers when negotiating contracts. And although no payment from the insurance company should be expected, the codes can be stacked. For example, if services are requested at 2 a.m. on a Sunday, use 99052 (services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) and 99054 (services requested on Sundays and holidays in addition to basic service). If the physician does not have regular office hours at 2 a.m. on a Sunday and is not operating a 24-hour walk-in clinic the physician can also use 99050.

99070 supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).

Of the 990xx series, this is the code most likely to be used. For orthopedists, 99070 can cover miscellaneous casting and strapping when they are not rendered as
part of a global service, as well as other durable medical equipment (DME). Code 99070 can be reported in addition to the casting code for materials used in casting or strapping. The cost of the materials should be itemized in the claim.

Whether you use 99070 depends on carrier preference. Many private and all Part B carriers will prefer a HCPCS DME or supply code over 99070, when one is available (e.g., A4590, special casting material [e.g., fiberglass]). But even using the corresponding HCPCS code instead is not without its wrinkles. Tammy Harwell, billing coordinator for Orthopedic Associates, LLP, a four-surgeon practice in Reno, Nev., explains that in Nevada, Medicaid does not recognize HCPCS codes, but Medicare, on the other hand, will not recognize 99070. Thus, for a crossover case, where both Medicaid and Medicare are assuming a portion of the cost of care, Harwell has to submit the claim to Medicare first using the HCPCS code, wait for payment, then rebill to Medicaid using the CPT code.

Harwell has also found that most commercial carriers prefer HCPCS codes for supplies, but for some items, there isnt a good code fit. The practice dispenses such items as therapeutic putty for physical rehabilitation, a metatarsal pad and a sports cord for rehab work. We code these as 99070, and always include a copy of the invoice as well as a letter explaining why the supply was needed, Harwell says.

Other coders have similar tales of HCPCS versus CPT codes for supplies. For workers comp cases, we usually get paid when submitting 99070, says Dana Shaw, a member of the billing team at Tricountry Orthopedics, a two-physician practice in Elkin, N.C., but it really depends on the carrier and what kind of supplies we are billing for. If using 99070, Shaw includes the product sheet or description, as well as the physicians notes as to why the item was dispensed. For Medicaid patents, when we get paid for the supply, its usually just a minute amount, she adds.

99071 educational supplies, such as books, tapes, and pamphlets, provided by the physician for the patients education at cost to physician.

Although there is a direct cost to the provider for these supplies and services, they are of a nonclinical nature. Most carriers will not reimburse for these goods because they expect the practice to build this type of expense into overhead.

99080 special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form.

This code is also a tough sell to insurance companies. Even if you can show that the insurer required extra paperwork, and that it involved more time and expense to prepare than your typical paperwork, the insurer usually takes the view that associated costs should be factored into your overhead. In other words, the insurer is paying for your clinical services at a rate that supposedly includes funds for those times when such reports are required.

990xx Codes So Why Bother?

As discouraging as it may sound, the 990xx series of codes does serve its purpose, and under the right conditions is reimbursable by some carriers. The first rule for payment is to use the 990xx codes only when no others are applicable. If a service can be assigned to another CPT code (or a HCPCS code, if your carrier accepts them) with a defined description, that is the best option. If there isnt a defined code that fits, or if the service really does fall under the miscellaneous code, coders should use the applicable 990xx code while also documenting the medical necessity of this service.

One key to obtaining payment for the 990xx series of codes is to negotiate for extra-contractual coverage. This means the insurer decides to pay even though it has no legal obligation to do so.

An insurer is more likely to pay if you can persuade it that covering the service will save money by avoiding more costly care. For instance, if you convince a case manager that treating a patient at home is necessary because the patient cant be transported and that home treatment is likely to prevent the need for costlier care later (like an ambulance or other form of transportation), the case manager should approve the extra payment for the home visit (99056, services provided at request of patient in a location other than physicians office which are normally provided in the office). The same may be true of opening up your office at midnight, rather than meeting the patient at the emergency department, where his or her merely setting foot in the door is going to incur cost.

In such cases, you should always contact the case manager before you render the service so he or she can approve the added payment. If you wait until after the service is rendered, the patient has already been helped at no cost to the insurer, so the case manager may disapprove the added reimbursement. Understandably, thats harder to do with emergency visits in the middle of the night. But by negotiating in advance with the payer, orthopedists can get a set idea as to whether or not their services will be covered.

The other benefit to reporting these codes deals more with the long term than immediate payoff. When the 990xx series is reported along with other CPT codes, even if unpaid, they do not result in the entire claim being denied. So if an orthopedist reports 29125 (application of short arm splint [forearm to hand]; static) with 99070, the 29125 will still be paid even if the 99070 is rejected. But over the long term, reporting codes for services rendered, even if the coder knows they will not be paid, impresses upon private carriers the need to consider payment for these codes. Change will not occur overnight, but if the message is consistent and clear enough, carriers may eventual liberalize their policies and start paying for legitimate services above and beyond the norm.