Revenue Cycle Insider

Keep detailed notes if conservative treatments have failed in the past.

Total knee replacements (TKRs), or total knee arthroplasties (TKAs), are among the more frequently coded orthopedic surgical procedures. However, coding for these procedures is not always straightforward. There will be evaluation and management (E/M) services as well as diagnostic services that take place beforehand that must be included in the claim.

Additionally, you must be proficient in coding the surgery itself and be aware of any necessary modifiers to avoid claim denials.

Read on for helpful hints and try out a few coding examples to build your confidence when it comes to coding these procedures.

Make Note of Conservative Treatments First

In many cases, a TKR will not be the first decision when it comes to treating a patient’s knee injury or pain. Many insurance companies will require you to include proof that nonsurgical options were explored before deciding on the arthroplasty route.

For this reason, be sure to keep detailed records of any alternative care, which could include specialized footwear, physical therapy (PT), medication, injections, weight loss, and, in some scenarios, even more minor surgical procedures prior to the TKR. Some of these procedures may include:

• Osteotomy: This procedure involves cutting and reshaping the bones of the knee to improve alignment and distribution of weight.
• Synovectomy: This procedure involves the removal of the synovial membrane that lines the knee joint if it becomes inflamed or overgrown.
• Microfracture surgery: The surgeon creates tiny fractures in the underlying bone to stimulate the growth of new cartilage.

Test Your Skills With These Encounter Examples

When more conservative treatments have failed or are not considered a viable option, prepare yourself by practicing with the coding examples below:

Coding example 1: The patient is a 74-year-old with right knee osteoarthritis (OA) who presents to the practitioner with an increase in their right knee pain. The patient states they have had significant pain for the last several years, but it has increased dramatically in the last month. They are planning a trip to Italy next year for their grandson’s wedding and would like to be healthy enough to sightsee and walk for long distances during the trip. They have tried ice packs, rest, elevating the knee, over-the-counter anti-inflammatory creams, and pain management injections without significant improvement. Today, they rate their pain as 4/10 sitting down; but with activity, they have severe pain. The patient would like to proceed with right TKR. After reviewing the patient’s medical record and history, the surgeon proceeds with TKR of the right knee.

For this encounter, your claim should look like this:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99203 to show that the E/M and surgery were separate, significantly identifiable services
• 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)) and modifier RT (Right side) for the TKR
• M17.11 (Unilateral primary osteoarthritis, right knee) appended to 99203 and 27447 to indicate the patient’s existing OA

Coding example 2: A 35-year-old semiprofessional basketball player visits the orthopedic office complaining of severe right knee pain, swelling, and major unsteadiness since last night’s game ended. The surgeon performs a history and physical exam and orders an MRI without contrast materials. After reviewing the MRI, the findings are consistent with severe damage to the meniscus that cannot be repaired with more conservative treatments. The surgeon diagnoses the patient with a complex tear of the medial meniscus and decides to perform a TKR on the patient.

For this encounter, your claim should look like this: 

• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99204 to show that the E/M and surgery were separate, significantly identifiable services
• 27447 for the total knee replacement
• 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) for the MRI 
• Modifier RT appended to 27447 and 73721 to indicate laterality
• S83.231A (Complex tear of medial meniscus, current injury, right knee, initial encounter) appended to 99204, 27447, and 73721 to represent the patient’s injury.
• Y92.310 (Basketball court as the place of occurrence of the external cause) appended to 99204, 27447, and 73721 as the external cause code to indicate where the patient was at the time the injury occurred

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC