Wiki 20985 and use of glenoid pin in sholder arthroplasty

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nsteinhauser

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Hello,
If anyone has any information about this, I'd really appreciate it.
Surgeon is doing a total shoulder and coding 20985 for the following dictation:
Based on preoperative imaging and/or planning, a glenoid pin was placed (20985). The glenoid was reamed to the appropriate depth, version, and inclination. The glenoid was prepared to receive the baseplate and central post. The glenoid baseplate was then impacted in place and screws placed for fixation. The glenosphere was then impacted into place.
Is this documentation enough to code the 20985?
Even though I can't find any LCD's or NCD's for 20985, I find commercial reimbursement policies that say the 20985 isn't covered, period. (experimental, investigational, or of no value to outcome)
Misc online info states 20985 is included in total knees, nothing about shoulders.
It's getting denied by a commercial Medicare product.
Thanks in advance.
 
This is a bit sketchy, as it is not documented well by the surgeon that a specific guide was used to place the wire based on specific measurements from preoperative templating. Some systems use the templating to give you specific dial-in numbers on a guide that fits over the Glenoid or some other form of patient specific instrumentation that might justify this code. The way this operative report is written, the surgeon is basically saying that he looked at the preoperative planning and eyeballed it. That does not pass the sniff test. If the surgeon feels otherwise, he is welcome to send it to the AAOS coding committee or the ASES Rep, and they will back me up.

I do not know of any commercial payers or Medicare advantage payers that reimburse this code, though there is not an NCCI edit, so technically it can be billed for traditional Medicare.
 
No one's going to pay for it.

Examples:
Anthem:
This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed.
UHC: Computer-assisted surgical navigation for musculoskeletal procedures of the pelvis and appendicular skeleton is unproven and not medically necessary due to insufficient evidence of efficacy. https://www.uhcprovider.com/content...r-assisted-surg-nav-musculoskeletal-procs.pdf

FL Blue: Computer-assisted surgical navigation for orthopedic procedures is considered experimental or investigational. The evidence is insufficient to determine the effects of the procedure on health outcomes. https://mcgs.bcbsfl.com/MCG?mcgId=02-20000-30&pv=false
 
nsteinhauser said:
Hello,
If anyone has any information about this, I'd really appreciate it.
Surgeon is doing a total shoulder and coding 20985 for the following dictation:
Based on preoperative imaging and/or planning, a glenoid pin was placed (20985). The glenoid was reamed to the appropriate depth, version, and inclination. The glenoid was prepared to receive the baseplate and central post. The glenoid baseplate was then impacted in place and screws placed for fixation. The glenosphere was then impacted into place.
Is this documentation enough to code the 20985?
Even though I can't find any LCD's or NCD's for 20985, I find commercial reimbursement policies that say the 20985 isn't covered, period. (experimental, investigational, or of no value to outcome)
Misc online info states 20985 is included in total knees, nothing about shoulders.
It's getting denied by a commercial Medicare product.
Thanks in advance.
Click to expand...
If there is a CT scan performed prior to the surgery, you would code 0055T. Just make sure that there is a copy of the CT Scan in the patient's chart. If the "computer assist" "robotic arm" or whatever term your provider uses is documented but there is not a CT scan, then 20985 is correct.
 
Now the surgeon is using this language:
"Based on preoperative computer-assisted planning and patient specific instrumentation, a glenoid pin was placed (20985). The glenoid was reamed to the appropriate depth, version and inclination. The glenoid was prepared to receive the baseplate and central post. The glenoid baseplate was them impacted into place and screws placed for fixation. The glenosphere was then impacted into place."

Is the addition of "computer assisted" and "patient specific instrumentation" enough to code the 20985?
I know it's not reimbursed but it's a Medicare patient so I could report it if the documentation supported it.

Thanks in advance!
 
No.
Tell him to just stop.
20985 is used when you are using real-time navigation based on intraoperative data. When you are using a CT- or MRI- based templating system, you cannot code it.
Dropping a few terms into the operative report doesn't suddenly change what he is doing. This is incorrect and a blatant attempt at overcoding.
 
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