Orthopedic Coding Alert

Watch your coding when reporting new paravertebral facet joint injection codes with other procedures, because you won't get paid for both, thanks to the Correct Coding Initiative (CCI). Get the lowdown on how to adhere to additional edits without giving away procedures.

Version 16.0 includes more than 649,000 active edits, according to Frank Cohen, MPA, of MIT Solutions, Inc., in Clearwater, Fla. With edits to the 20000-29999 code family comprising more than 25 percent of all active edits, you can't afford to miss any of the changes.

Many Jan.1 orthopedic-related edits involve new codes 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [sygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level) and 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [sygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level). CCI 16.0 lists 64490 and 64493 as components of most musculoskeletal codes in the 22xxx family and virtually all spinal codes (62263-64999).

Warning: CCI assigns a modifier indicator of "0" to the edit pairs involving 64490 and 64493. That means you cannot use a modifier under any circumstances to bypass the edit and report both codes for a single patient encounter.

As you sift through CCI 16.0, don't miss a few edits that apply when your orthopedic surgeon performs the procedure and also provides the moderate sedation. "There are two separate families of moderate sedation codes," points out Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. The codes break down into the following groups:

• For sedation provided by a physician other than the one performing the procedure, use 99148-99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports ...).

• If the physician who performs the procedure also provides the moderate sedation, you would bill codes 99143-99145 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status ...).

Vertebroplasty components 22520 (Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic) and 22521 (... lumbar) now include the surgeon-provided sedation codes 99143-+99145.

Translation: If your surgeon performs the vertebroplasty and provides sedation during the procedure, you cannot separately report the sedation. None of these moderate sedation edits offer an edit bypass option. They carry a modifier indicator of "0," so skip the sedation code.

Don't let the "switched edits" information slip under your radar, because CCI 16.0 changes the column 1 and column 2 designations for quite a few procedures.

Example: Previous versions of CCI listed 64718 (Neuroplasty and/or transposition; ulnar nerve at elbow) as a comprehensive code when paired with 24400 (Osteotomy, humerus, with or without internal fixation).

CCI 16.0 reverses that designation, however, and now lists 24400 as the comprehensive procedure and 64718 as the component. Be sure to file your claim with each code in the correct place for the newly switched pairs, or you'll find yourself facing denials.

File 63685-59, 63688 for Two Generators -- Maybe At least CCI does bring you one gift: You can now separately report different generator revision and removal in some situations.

For neurostimulator procedures 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver)

the modifier indicator changes from "0" to "1." The change means you can report the procedures together under certain circumstances.

Action: If your provider repositions the same generator, you cannot report both codes. CPT supports this rule with the notation, "Do not report 63685 in conjunction with 63688 for the same pulse generator or receiver." If your physician removes one pulse generator and puts in another, however, you can submit both codes.

CCI 16.0 includes an extensive list of terminated code pairs, but don't let the list worry you. "The deletions primarily involve codes that were either deleted from CPT 2010 or the consultation codes that are no longer covered by Medicare," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

The edits apply to deleted injection codes 64470 and 64475, plus consultation codes 99241-99245 (Office consultation for a new or established patient ...) and 99251-99255 (Inpatient consultation for a new or established patient ...).

As extensive as CCI 16.0 edits are, they apply only to payers that follow CCI.  "Many non-Medicare payers follow CCI edits when developing their bundling edits, but you can follow the AMA's guidance when billing non-Medicare payers," Mehmert says.

Example: CCI edits bundle 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device) into 64510 (Injection, anesthetic agent; stellate ganglion [cervical sympathetic]), but the AMA currently does not. Therefore, you can bill 77002 with 64510 if you're submitting to a non- Medicare payer that doesn't follow CCI edits.