Orthopedic Coding Alert

Orthopedic coders often express frustration with coding for arthroscopic superior labrum anterior/posterior repairs, commonly known as SLAP repairs. Although the procedure is a fairly common shoulder repair, only an unlisted code is available to describe it. Given this limitation, orthopedic coders should develop a strategy when working with payers to ethically maximize reimbursement and minimize appeals.

The only viable code that exists for submitting claims for arthroscopic SLAP lesion repair is 29909 (unlisted procedure, arthroscopy). But orthopedic coders still have difficulty determining the best way to get paid for the procedure. The difficulty coders encounter when working with a variety of different orthopedic procedures is that there just arent enough codes to describe all the ligaments in the body, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm based in Spring Lake, N.J.

Brink adds that too often, orthopedic coders will show a number of possible codes to their surgeon, and the surgeon will pick one thats similar to the SLAP repair. The problem with this method, however, is that its improper coding. You cant use a code that sort of fits, Brink says. You have to code for what was done, and at the present time no CPT code describes a SLAP lesion repair.

Coders resist the unlisted procedure code because its use often results in a claim delay or denial followed by an appeals process. Naturally, coders want to avoid appeals and speed up the payment process, Brink says. But applying an incorrect code to try to ensure payment is still a bad option.

Strategies With 29909

Although there are limited code choices for a SLAP lesion repair, the avenue to reimbursement lies in proving to the payer what the surgeon did and how it should be reimbursed. Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., where she works with 11 physicians representing various orthopedic specialties, always submits claims for SLAP lesion repairs with a brief letter from the surgeon (see box on page 20). The letter describes the procedure and compares it to a Bankart lesion repair (23455, capsulorrhaphy, anterior; with labral repair [e.g., Bankart procedure]). The claim is still for the unlisted procedure 29909, but uses the Bankart 23455 as a reference for determining reimbursement. Stouts physician has determined that the SLAP lesion repair is about 10 percent more work than the Bankart lesion repair, so the claim is for 110 percent of what the carrier would pay for the Bankart.

This is a good tactic, Brink says. With unlisted codes, you have to justify what you are charging for. Comparing and contrasting the SLAP lesion repair to the Bankart lesion repair for which there is an existing code gives the carrier a better idea of what reimbursement should be. Because of the risk of reductions when using unlisted codes, ask for a specific amount rather than leaving it to the carrier to determine reimbursement.

The letter should be as simple and to the point as possible. A standard letter, like the one included here, can be kept on file and tailored to each patient. Brink adds that the surgeon, and not the coder, should write and sign the letter.

There is another strategic aspect to using unlisted codes as well. Frequent use of unlisted codes is one way that the AMA and HCFA know when it is time to create a new code. When an orthopedic surgeon writes to the AMA, HCFA or the American Academy of Orthopedic Surgeons, she or he can cite the number of times unlisted codes were used when no other options were available. Lobbying efforts like this are one of the few ways practitioners have to get new codes created. And with arthroscopy playing a larger role in orthopedic surgery, new codes or modifications to existing codes are a must.

A Proactive Step

One way to avoid denials with SLAP lesion repairs is to contact your major payers in advance of submitting claims. This is a particularly important step for sports medicine practices, or practices that perform a large number of SLAP lesion repairs. Ask each of them how they want to handle claims for the procedure. When calling the claims departments, talk to someone in a decision-making capacity who can give you concrete input on how to submit these claims.

But use of 29909, even with proper documentation, doesnt solve the problem of carriers who just wont accept unlisted codes. When a payer doesnt recognize an unlisted code, it is automatically denied. Brink recommends that coders be proactive, rather than reactive, and talk to the carrier first. If the carrier says they dont accept unlisted codes, Brink says, then youve got a problem that you need to work out with them. Obviously, the practice wont stop doing SLAP lesion repairs, so the carrier needs to work with you to determine the best coding and billing technique to ensure reimbursement.