Orthopedic Coding Alert

Core decompressions of the hip are a fairly common orthopedic procedure. Yet no CPT code accurately describes the process. Appropriate reimbursement for the procedure means choosing either an unlisted code or a similar code, depending on carrier preference.

Some coders opt to use 26992 (incision, bone cortex, pelvis and/or hip joint [e.g., osteomyelitis or bone abscess]) for core decompressions. This is an alternative to using an unlisted procedure code (27299, unlisted procedure, pelvis or hip joint) because many providers like to avoid using unlisted codes whenever possible. But 26992 may not accurately describe a core decompression. And while many coders prefer to use an analogous code to an unlisted one, 26992 leaves out both the removal of the necrotic tissue and the bone graft two common elements of the procedure.

Denise Paige, CPC, coding and billing manager for Beach Orthopedic Associates, a four-doctor orthopedic practice in Long Beach, Calif., has reservations about using 26992. I have a surgical cross-coding guide that says 26992 is only for diagnoses that pertain to osteomyelitis and infections (730.xx, osteomyelitis, periostitis, and infections involving bone). Because a core decompression of the hip is usually done for avascular necrosis (733.42, aseptic necrosis of bone; head and neck of femur), a claim using 26992 for a core decompression may get rejected for the wrong pairing of diagnostic and procedural codes. Instead, Paige uses the unlisted code when billing for the procedure.

Two Ways to Code the Decompression

Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., works with 11 physicians representing various orthopedic specialties and has success in coding the core decompression of a hip in two different ways. For carriers that accept an unlisted procedure code, she submits 27299 with the operative report and a letter explaining the surgery in lay terms. If a carrier will not process a claim with an unlisted procedure code and many HMOs will not Stouts surgeons use 27071 (partial excision [craterization, saucerization] [e.g., osteomyelitis or bone abscess]; deep [subfascial or intramuscular]).

When choosing an analogous code like 27071 to report a core decompression of the hip, remember that you are attempting to file the claim with the closest matching code possible without exceeding the procedures worth. Stout is a proponent of 27071 for a core decompression of the hip because the objectives of the two procedures are similar to remove nonviable bone and the surgical techniques are similar.

Coding the Graft

When using 27299, 27071 or 26992, the grafting segment of the surgery may be billable separately depending on circumstance. The surgery that Stout describes includes a graft of demineralized bone matrix, or an allograft. Allograft material is harvested from cadavers. Because the orthopedic physician does not do the harvesting, he or she cannot bill for the graft. If the graft was in the form of an autograft, however, that means the graft material came from another location on the patients body. Because the surgeon is harvesting the graft in the same operative setting as the core decompression, the graft can be coded separately, with either 20900 (bone graft, any donor area; minor or small [e.g., dowel or button]) or 20902 (... major or large).

Pros and Cons of 27299

There are reimbursement challenges to using unlisted codes. Although the AMA dictates that unlisted procedure codes are to be used when no analogous code exists to describe a procedure accurately, many carriers either refuse to process these claims or hold them for a long time as they pass through the review process. When this situation exists, one has no choice but to submit the claim with the analogous code that is the closest match possible with appropriate supporting documentation. Also, assuming the carrier accepts unlisted codes, coders are often reluctant to use them because the carrier doesnt have a specific procedure upon which to base payment, affecting the accuracy of reimbursement. Without a code value to compare the core decompression and subsequent graft, the service performed may be of a higher level than the reimbursement that follows.

Coders can make some headway in reimbursement for the core decompression of a hip by working with carriers to educate them on the procedure. If core decompressions or any unlisted procedures are done by the practice on a regular basis, most carriers will develop a fee for the procedure based on the information submitted. The key is to make sure the carrier has a solid understanding of what the decompression entails. A one- or two-line operative report is not sufficient to describe an unlisted procedure. Instead, a cover letter with a thorough explanation of the decompression is necessary to impress upon payers the true level of service. If the bone graft is not always a part of the core decompression, this should be mentioned in the cover letter as well.

Some coding experts recommend having a descriptive boiler plate letter on hand that is used every time a core decompression of the hip is performed. The letter should offer a comparison code and essentially state: We feel this surgery should be valued similarly to code [appropriate code] for these reasons. The letter keeps you from having to reinvent the wheel with each claim for a core decompression.

An even better approach, Stout suggests, is to be proactive and submit documentation before the procedure takes place and negotiate reimbursement before the fact rather than after.

Prospective review is an effective method of optimizing reimbursement that should be utilized rather than fighting it out with the carrier after the service has been rendered, Stout says.