Orthopedic Coding Alert

Do you know how to handle coding for more than one arthroscopic service performed at a single surgical session? Your reimbursement depends on it.

The scenario is familiar, but the coding requirements may not be: The orthopedist performs arthroscopic shoulder surgery (29819), an acromioplasty (29826) and a distal clavicle resection (29824). Because these codes are in the same family, Medicare's multiple-endoscopy rule, not the standard multiple-procedures rule, governs your reimbursement.

In CPT, a "family" of codes is designated by a non-indented code followed by a group of indented codes. For example, Utah Medicare's March 2003 Part B Update lists 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy [separate procedure]) as the base code in the endoscopic family that includes codes 29806-29826. (See our article "Get to Know Your Families" for a list of the arthroscopic families.)

Medicare carriers would reimburse claims for 29819 (Arthroscopy, shoulder, surgical; with removal of loose body or foreign body), 29826 (... decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) and 29824 (... distal claviculectomy including distal articular surface [Mumford procedure]) using CMS' multiple-endoscopy rule instead of the multiple-procedures rule.

Most orthopedic coders are all too familiar with Medicare's "multiple surgeries" regulation. According to section 15038 of the Medicare Carriers Manual (MCM), if you report two or more surgical procedures (not in the same family) on the same day, Medicare will pay the first procedure at the full relative value unit (RVU) allowable rate but will discount the second through fifth procedures by 50 percent.

Some carriers automatically append modifier -51 (Multiple procedures) to these claims, although other payers require the practice personally to append modifier -51 to the second and subsequent procedures.

Medicare maintains a separate payment rule, however, for multiple endoscopies. The MCM states, "For multiple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy." This means that if the base endoscopy has 15 RVUs, your primary endoscopic procedure carries 25 RVUs and your second endoscopic procedure from the same family has 20 RVUs, Medicare will only pay five RVUs for the second procedure, because this is the difference between the base procedure and the lesser-valued surgical endoscopy.

"Reimbursement subject to Medicare's multiple-endoscopy rule is not also subject to the multiple-procedures guidelines," says Dolores Kesemere, billing manager at Professional Orthopedic Associates in Tinton Falls, N.J. If your carrier reduces your claim based on the multiple-endoscopy rule and also takes a multiple-procedures discount off of that amount, you should appeal your claim and ensure that the carrier issues you additional reimbursement.

To avoid receiving a "double discount," most consultants advise against appending modifier -51 to multiple arthroscopies that you perform in the same family of codes. Otherwise, the insurer's computer system might automatically take both reductions.

The only exception to this rule is when you perform arthroscopies in two different families. If you perform diagnostic arthroscopy in the knee and surgical arthroscopy in the shoulder, for example, you should append modifier -51 to the knee scope code, and your carrier will apply the multiple-procedure rule to that service, says Malea Ivy, RHIT, coder at the Orthopedic and Neurosurgical Center of the Cascades in Bend, Ore.

Your insurer will apply both discounts only if you perform several procedures from separate families. For example, if you perform two arthroscopic procedures from the same shoulder family and two from the same knee family, Medicare will apply the multiple-endoscopy rules to each family of procedures and will then apply the standard multiple-surgical procedure discount to the lesser-valued group of codes. 
 
Use Multiple-Endoscopy Rules for Scopes

What puzzles most orthopedic coders is why multiple-endoscopy rules apply to arthroscopic procedures. After all, "endoscopy" and "arthroscopy" are not interchangeable terms.

"Medicare has bundled all scopes into the multiple-endoscopy rule because all scope procedures include both a diagnostic and a surgical scope," Ivy says. And even though the MCM's multiple-endoscopy rule doesn't specify that multiple arthroscopies are included, carriers use this rule to process arthroscopic claims that occur in the same family.

In addition, most states maintain this regulation in their written guidelines. Chapter 5221 of the Minnesota Legislature's Rules, for example, states, "The multiple endoscopy payment rules apply if the procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). For purposes of this item, the term 'endoscopy' also includes arthroscopy procedures."

When Medicare's multiple-endoscopy rule applies, you can expect to be reimbursed 100 percent for the highest-valued procedure, which means you should sequence your multiple arthroscopic procedure codes starting with the procedure with the highest RVUs. In the example above, 29819 carries the highest RVU, so you should list it first on your claim.