Orthopedic Coding Alert

 Want to know what you can bill with your arthroscopy claims? Look no further

We've compiled five of our subscribers' most pressing knee coding questions and asked our experts how to code them. Read on to firm up your knee coding knowledge.

Bypass Limited Synovectomy Bundles

Question 1: When the surgeons perform separate compartment synovectomy with meniscectomy, which code combination should we report?

Answer: You have two coding choices when your surgeon performs synovectomies: 29875 (Arthroscopy, knee, surgical; synovectomy, limited [separate procedure]) and 29876  (... synovectomy, major, two or more compartments), says Susan Vogelberger, CPC, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

"The National Correct Coding Initiative bundles 29875 into meniscectomy (29881), but the major synovectomy (29876) is not bundled and can be billed in addition to 29881," Vogelberger says.

Here's how you tell whether the synovectomy is limited or major: If the physician doesn't specifically use the word "compartment" to designate the extent of the procedure, look in your operative report for the phrase "plica resection." This term indicates a limited synovectomy. Some surgeons refer to limited synovectomies as "shelf resections."

The knee consists of three compartments - medial, lateral and patello-femoral - and limited synovectomies include only one area (or compartment) of the knee.

A major synovectomy includes two or more of these areas (or "joint locations"), and is a long and tedious procedure intended to treat extensively diseased internal joint lining as seen in rheumatoid arthritis, pigmented villonodular synovitis or hemophilia.

Therefore, if your surgeon performs a medial meniscectomy and medial and lateral synovectomies, you should report 29881 (Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]) and 29876.

ACL Repair With Meniscectomy? Break out the Modifiers

Question 2: Our surgeon performed an arthroscopic-aided anterior cruciate ligament (ACL) repair, with repair of the medial meniscus and partial lateral meniscectomy. Which codes should we report?

Answer: You should report three codes on three separate lines, as follows:

29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) for the ACL repair

29882-51-59 (Arthroscopy, knee, surgical; with meniscus repair [medial OR lateral]; Multiple procedures; Distinct procedural service) for the medial meniscus repair

29881-59 for the partial lateral meniscectomy.

The surgeon cannot repair and excise the same meniscus, so because he repaired the medial meniscus and excised the lateral meniscus, you can report both codes.
The operative note should clearly indicate that the surgeon addressed both the lateral and medial menisci to ensure that the payer reimburses both procedures.

Tread Carefully With Debridement, Meniscectomy

Question 3: Our surgeon performed an arthroscopic partial medial meniscectomy and then debrided the anterior cruciate ligament stump. Can we report both 29881 and 29877 to the patient's Blue Cross insurer?

Answer: No. You should report only 29881 for this combination, says Jay Neal, an independent coding consultant in Atlanta.

Although some surgeons erroneously report 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chondroplasty]) with 29881, "the American Academy of Orthopaedic Surgeons includes ACL debridement as part of 29881," Neal says. In addition, the National Correct Coding Initiative bundles 29877 into 29881.

2 Meniscectomies Equal 1 Code

Question 4: How should we report separate compartment meniscectomies? In other words, which codes can we bill if the surgeon performs meniscectomy in more than one compartment at a time? 

Answer: "Meniscectomies can and often are performed in more than one compartment," Vogelberger says.

Code 29881 describes a meniscectomy in either the medial or lateral compartment, whereas 29880 (Arthroscopy, knee, surgical; with meniscectomy [medial AND lateral, including any meniscal shaving]) refers to meniscectomies in both the medial and lateral compartments, Vogelberger says.

Therefore, if your surgeon performs medial and lateral meniscectomies on the same knee at the same time, report one unit of 29880.
 
Exception: The only time you can report two units of 29881 during medial and lateral meniscectomies is in the rare case that your surgeon performs them on separate knees.

For example, if she performs a medial meniscectomy on the left knee and a lateral meniscectomy on the right knee, you should report 29881-LT (Left side) and 29881-RT (Right side), along with a copy of your operative report.

Append 22 for Revised Reconstructions

Question 5: Another orthopedic surgeon performed a faulty ACL reconstruction on a patient, and our surgeon had to go in and perform an enormously complex revision of the reconstruction to repair the problem. How should we report our revision?

Answer: Sometimes patients can walk around for years with a flawed ACL reconstruction, only to reinjure themselves playing sports or twisting their knees. Unfortunately, only one code describes these taxing and time-consuming operations: 29888.

The problem is that the ACL revision can be more complex than what 29888 describes. For example, your surgeon may have to remove the hardware that the other  surgeon left in place, take out a previously placed tendon graft, and revise tibial and/or femoral tunnels. Also, scar tissue may make surgical dissection more complicated.

You should convey all of the extra hard work by adding modifier 22 (Unusual procedural services) to 29888. Submit supporting documentation along with the claim, explaining why you appended the modifier and how the revision differed from the initial repair/reconstruction.