Orthopedic Coding Alert

Make certain you know what a TKR global package includes.

To successfully report a total knee replacement (TKR), you have to understand more than simply the CPT^® codes — you have to navigate modifiers as well as have full knowledge of what’s included in the global surgical package.

Tackle This Scenario

An obese 45-year-old woman suffering from end stage (degenerative) arthritis endured as much pain and loss of mobility in her knees as she could tolerate. Despite her relatively young age and the difficulty she would have during rehabilitation because of her weight, she and her orthopedic surgeon (OS) agreed during an office visit that she should have a Total Knee Replacement (TKR) in each knee.

To provide the best chance of successful rehabilitation, the orthopedic surgeon replaces only the right knee. After the woman regains function in that knee, the orthopedic surgeon will replace the left knee.

Now, Break Down Your CPT® Options

Diagnosis: The diagnosis for the woman’s condition is degenerative arthritis, which you would report with M17.0 (Bilateral primary osteoarthritis of knee). The woman’s obesity is of unspecified origin, so you should use E66.9 (Obesity, unspecified). If the orthopedic surgeon documents this as exacerbating her knee problems, you should list this as a secondary diagnosis.

Decision for surgery: At the encounter when the orthopedic surgeon decided to perform the surgery, you should report the appropriate level of established patient evaluation and management (E/M) service (99211-99215) and apply modifier 57 (Decision for surgery).

CPT^®: A total joint replacement is sometimes called an arthroplasty. An arthroplasty is a reconstructive surgery of a joint to restore motion. But not all arthroplasty involves all the components required to make it a TKR in the lexicon of CPT^®. A knee replacement can be a total knee or a single component. The components are medial and lateral. Therefore, you must read the operative report to ensure that it is truly a total knee.

The correct code for a total knee replacement is 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee replacement]). If only a medial or lateral component is the target of the replacement (unicondylar knee replacement), use 27446 (Arthroplasty, knee, condyle and plateau; medial OR lateral compartment).

Special Coding Considerations

Modifiers: You can use modifier RT (Right side) or LT (Left side) when coding 27447. If the knee replacement is bilateral, use modifier 50 (Bilateral procedure) and double the normal fee. Many carriers will reimburse only the bilateral procedure at 150 percent of the single one. Keep in mind: Some insurance companies might give a decreased fee for a bilateral; it varies, experts say.

Global period: The global surgery package is 90 days, according to CMS. The global package components include:

• synovectomy,
• removal of loose bodies,
• debridement of the knee, excision of osteophytes
• meniscectomy, medial or lateral
• lateral retinacular release,
• ligament or capsular release or reconstruction,
• manipulation of knee and arthrotomy
• diagnostic arthroscopy.

Note: These components are an American Academy of Orthopaedic Surgeons (AAOS) guideline.

Good idea: Do not try to code separately for any of those procedures or it will constitute unbundling.

Example: Suppose a patient goes to a VA (Veterans Administration) facility for the TKR and after having the replacement, wants to be seen by an orthopedist (in private practice for post-op follow-up care).

Solution: Because the patient is arriving to the orthopedist after surgery and the orthopedist takes over care during the global period, you would attach modifier 55 (Postoperative management only) to 27447 by the orthopedist. The orthopedist at the VA hospital would be required to submit 27447 with modifier 54 (Surgical care only).

An orthopedist in Florida who sees a winter visitor who had a TKR in New York just before traveling often does not know whether the orthopedic surgeon in New York used a modifier. As you know, you can use E/M codes from the beginning for follow-up care, but you are obligated to use modifier 54 when you know it applies. Even if the orthopedic surgeon does not know, an insurance company may follow a payment trail later and ask the orthopedic surgeon to pay back a portion of the money allotted for a global package.

When The TKR Fails, Look to These Codes

You will have separate CPT^® codes for revision surgery. If the failure of the TKR requires a revision to only one component, use 27486 (Revision of total knee arthroplasty, with or without allograft; one component). For the entire knee, use 27487 (Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component).

If the knee fails during the global period (for 27447), use modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) with 27487, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of HealthCare Resource Management, Spring Lake, N.J. And always send a copy of the operative note.