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, COSC, CCS-P, director of orthopedic coding services at The Coding Network. "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 are billing.

Example: The surgeon performs core decompression for a condition such as avascular necrosis. You should report the unlisted-procedure code 27299 (Unlisted procedure, pelvis or hip joint), says Jodi Elfner, CPC, CPC-H, coder at Orthopaedic and Spine Specialists in York, Pa.

Your documentation should fully describe the procedure, including a letter from the surgeon explaining the need for core decompression, and you should also submit a copy of the operative report with the claim.

Compare the Procedure to an Existing Code

If you want to gain appropriate payment for an unlisted-procedure claim, you should provide the insurer with an appropriate place to begin. Often, insurers pay for an unlisted-procedure claim by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value.

Take charge of your claim: Rather than allow the insurer to determine the "next closest" code on which it should base your payment, you should explicitly reference the nearest equivalent listed procedure in your explanatory note.

Why: If you let the insurer choose the comparison code for you, you could end up having to fight it later. For instance, the payer might compare your claim to something valued much lower than the unlisted procedure that your physician performed.

Provide specific details: You should also note how the unlisted procedure differs from the next-closest listed procedure.

Answer these questions: Was the unlisted procedure more or less difficult than the comparison procedure? Did it take longer to complete and, if so, by how much (try to provide percentages whenever possible)? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill or equipment? Any of these factors can make a difference in the reimbursement level you may expect.

Example: CPT does not include a code to describe laminotomy and excision of herniated thoracic disc (the only thoracic codes correspond to transpedicular or costovertebral approach). CPT, however, does include codes to describe cervical (63020) and lumbar (63030) excisions. To report thoracic laminotomy, you may cite 64999 and include an explanation with the claim stating, "Surgeon performed laminotomy with discectomy, similar to that described by 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, cervical), but occurring in the thoracic region. Due to the anatomic difference in vertebrae structure, the work involved was roughly 10 percent greater than that described by 63020."