Wiki Billing Multiple units of 25320

[ndguenther]

My hand surgeon is insistent that CPT 25320 can be billed with multiple units because he did 3 different ligament repairs. I know that CMS has an MUE of 1, which I have explained to him, but he is still insisting to add a modifier. I do not agree with this due to the CPT description stating that multiple ligamentous repairs may be needed. Has anyone else experienced this with a doctor and is there any articles that will help me provide to him that this is not appropriate? Thanks for any help.

 

[sls314]

My hand surgeon is insistent that CPT 25320 can be billed with multiple units because he did 3 different ligament repairs. I know that CMS has an MUE of 1, which I have explained to him, but he is still insisting to add a modifier. I do not agree with this due to the CPT description stating that multiple ligamentous repairs may be needed. Has anyone else experienced this with a doctor and is there any articles that will help me provide to him that this is not appropriate? Thanks for any help.

You are correct. The MUE is 1, and you can't bill for multiple units. The code's definition says "Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability"

It includes ligament repair and does not specify "per ligament." The procedure is bilateral eligible, so it could be billed with a 50 modifier if both wrists were repaired on the same date. You just can't bill more than one unit for the same wrist. One wrist, one unit.

If you look in the MUE Adjudication Indicator (MAI) column for CPT 25320, you'll see that it is indicator type "2 Date of Service Edit: Policy"

Edits for HCPCS Level II/CPT® codes with an MAI of 2 are absolute date of service edits. These are per day edits, based on policy. Units of service on the same date of service in excess of the MUE value would be considered impossible because billing in this fashion would be contrary to Medicare statute, regulations, or guidance.

 

[MI_CODER]

I'd also just like to add that the CPT lay description for 25320 specifically states this code includes the reduction and repair of any number of ligamentous injuries.

CPT Lay Description 25320
The physician performs an open capsulorrhaphy or reconstruction of the wrist by any method (capsulodesis, ligament repair, tendon transfer, or graft), including synovectomy, capsulotomy, and open reduction to stem carpal instability. The wrist and finger extensors are retracted laterally and medially. The capsule is longitudinally cut over the involved carpus for exposure. If dislocation was present prior to surgery, this is reduced. The necessary fixation is carried out (i.e., Kirchner wires, screws). Carpal instability may result from dislocation of carpal bones and any number of ligamentous injuries that require reduction and repair, involving the joint capsule. Scapholunate dissociation and instability is one of the most common injuries. Dorsal intercarpal ligament capsulodesis may be performed to reduce the scapholunate gap. A flap of dorsal intercarpal ligament is elevated off the trapezoid and left attached to the triquetrum. The scaphoid inherently tends to sublux in the palmar direction in a flexed posture with dorsal rotational subluxation of the posterior pole. The scaphoid is brought out of its flexed position by applying dorsal pressure to the posterior pole and the scapholunate gap is reduced. The ligamentous flap is rotated down, stretched, and attached to the distal pole of the scaphoid. A flap of wrist capsule may also be created that is left attached to the radius and inserted into the distal pole of the scaphoid to tether it in chronic conditions.