Orthopedic Coding Alert

Follow the experts- guidance to getting these claims reimbursed CPT doesn't always match up with what your orthopedist does, and there are a few easy steps you can take to show carriers what to do with your unlisted- procedure claims. CPT includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT descriptor available. Payment for such claims, however, is not automatic. Your orthopedic surgeon must make a careful effort to document the procedure, and the information you include with your claim can make all the difference. Don't Approximate The only time you should call on an unlisted- procedure code (for example, 27599, Unlisted procedure, femur or knee; or 29999, Unlisted procedure, arthroscopy) is when no CPT code properly describes the procedure your physician performs. By the same token, however, you shouldn't select a code that is "close enough" in place of an unlisted- procedure code. For instance: If the surgeon performs a rotator cuff reconstruction with tissue scaffolding as an arthroscopic procedure, you should report 29999 (Unlisted procedure arthroscopy) because there is no arthroscopic counterpart to 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]). Helpful hint: You can find a complete list of unlisted- service codes by anatomical/specialty area in the "Guidelines" portion of each CPT section. Roll up your sleeves: Reporting an unlisted-procedure code will require a special letter of explanation to describe the service. But correct coding demands that you use a code that most accurately represents the service the orthopedist provides, not a code that is similar but actually represents a different service. Watch your global: In addition, some payers do not assign any global period to an unlisted-procedure code, so you should query your major payers to determine their global periods for unlisted-procedure codes, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. "For some, you may be able to bill for E/M services postoperatively." Describe the Procedure in Plain English Anytime you file a claim using an unlisted-procedure code, you should submit a cover letter of explanation and the full documentation of services. Here's why: Insurers consider claims for unlisted- procedure codes on a case-by-case basis. If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved. An important part of the coder's task in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms. Keep it simple: Avoid or explain medical jargon and difficult terminology. If appropriate, include diagrams or photographs to help describe the procedure you [...]