Part B Insider (Multispecialty) Coding Alert

Published on Tue Feb 10, 2004 PDF

Send letter explaining how procedure differed from normal reconstruction

Another surgeon goofed, so your surgeon has to go in and perform an enormously complex revision of his reconstruction of the anterior cruciate ligament. How should you code it?

Sometimes patients can walk around for years with a flawed ACL reconstruction, only to reinjure themselves playing sports or twisting their knees. Unfortunately, there's only one code for these taxing and time-consuming operations: CPT 29888 (Arthro-scopically aided anterior cruciate ligament repair/augmentation or reconstruction). How do you convey the extra work your physician did?

There are a number of factors that can make an ACL revision more complex than an ACL repair or reconstruction, says Heidi Stout, coding and reimbursement manager of University Orthopedic Associates in New Brunswick, N.J. These can include removing the hardware the previous surgeon left in place, taking out a previously placed tendon graft, and revising tibial and/or femoral tunnels. Also, scar tissue may make surgical dissection more complicated.

She tries to convey all this hard work by adding modifier -22 (Unusual procedural services) to 29888. Submit supporting documentation along with the claim explaining the use of this modifier. Stout sends a letter that "explains how the revision differed from the initial repair/reconstruction."

It's also important to include the added percentage of reimbursement the physician believes the extra work deserves, says Malea Ivy, a coder with the Orthopaedic & Neurosurgical Center of the Cascades in Bend, Ore. If the physician documents "why, what and how much more difficult the procedure was in the operative report, I can easily extract that information for an explanatory letter and ask for additional reimbursement on their behalf," she adds.

Use the appropriate ICD-9 codes, including 844.2 or 717.83 for the ACL tear and 996.4 (Mechanical complication of internal orthopedic device, implant and graft) for the torn graft, says Mary Brown, orthopedic coding specialist at OrthoWest in Omaha, Neb.

Anytime you use modifier -22 or code for complex surgeries, you should make sure the payer actually reimbursed more than the standard payment, Brown says. You should appeal a non-upgraded payment just as you would a denial, and ask for a board-certified orthopedic surgeon to review the claim.