Wiki Bone graft code 20900 correct coding

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jdibble

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Hi Coders!

I need some help or opinions on the use of 20900. I have a shoulder surgeon, who wants to bill 20900 with a reverse total shoulder arthroplasty, 23472. I know there is no bundling with the two codes, however it is stated that the bone graft is obtained from a different incision. This doctor used bone from the humeral head. When I gave him information on the use of 20900 and how it was not billable if from the same incision, he still insisted that he can use it saying, "it was a graft from the removed humeral head". He also says it has been previously accepted which I am assuming from his previous coders. Mind you, we have just recently started coding for this provider group and this provider likes to try and bill for everything.

My question is, should the bone graft be billed or is it not billable based on how the graft was obtained? If you can also provide some proof as to why it is or isn't I would appreciate that since I have to go back to him again with the reasoning.

Thanks!
Jodi
 
First Q: Does the bone graft say minor/small as in dowel or button? Because the 20900 is for small. I doubt that's what this is. It's probably large which would be 20902. So if they have been reporting 20900, that is not correct anyway, aside from bundling or other issues. I think someone should audit their old stuff, that's scary. Depending on the documentation, of course. There's no way this would only be 20900 if they are using it to build up the glenoid.
Second Q: Is it humeral head autograft placed into the glenoid?
Third Q: Did you check CPT Assistant? I think it is in December 2000 CPT Assistant and says something like, 'The bone graft codes 20900 and 20902 are separately reportable only when the graft material is an autograft and is obtained through a separate incision and not listed as part of the basic procedure.' Please check that because I don't have access to it right now, but I am pretty sure that's where it is. That would be your definitive reference.

There might not be an edit, but that doesn't make it right. It would have to be from a separate incision or distant site. This is not that, it is being taken from the humeral head at the same site as the surgery where the humeral head is removed/replaced. My copy of the AAOS GSD is not current, but you can check the current one for the global included items. If you have Code-X it should be in there.

Another thing is, depending on how the practice is setup, I have seen where all codes are captured for RVUs and/or production within the billing system but not all are reported on the claim. Just a thought. Does he want to capture everything within the system internally for that, or is he really talking about billing everything on the claim?

Also, depending on the documentation, if the documentation of the TSA was over and above the work normally required for a TSA, modifier 22 "might" be an option. It has to meet the definition of the modifier though.
 
Amy, Thank you for your response. Basically, he is removing the humeral head during an arthroplasty, no separate incision. He takes some of the humeral bone and mixes with tobramycin. Here is that portion of the OP note:

Autograft bone grafting 20900

Bone graft from the humeral head and from the metaphyseal reaming was used as bone graft prior to implantation. This was mixed with tobramycin powder. In total 7-10 cc of autogenous bone graft was used.

He is insisting that the code can be used since the bone is from the patient!! I explained the same incision is not acceptable, but he is not accepting that! I need written proof that it cannot be billed in the way he has done the graft.

He has a number of these procedures and on every surgery, he wants to bill for the bone graft. I do not have access to the AAOS GSD, Code-X or CPT Assistant, but if that is the statement from there, that may be the proof I need. The doctor gets credit for RVUs but only if it is a billable code and that is why he keeps fighting with me on coding codes that are either bundled or not billable for what he did.

If someone can post the CPT assistant rule with the source, then I can try and copy that and send that to him!

Thanks!!
 
If you are exclusively coding orthopedics and don't have any of those references you mentioned, you are really working with a big disadvantage. Are your surgeries at least run through an RVU and NCCI edit checker before billing?
Has anyone taken a look at data analytics on denials/rejections and/or take-backs for these cases? Has the provider gotten any audit or other medical record documentation requests? Do plans often ask for records like in a pre-pay scenario before paying claims? If it is 7-10cc I guess you could call that small however, you still can't code that when it is taken from the same site/humeral head which was removed for the TSA. What else is he trying to unbundle? Just because there is no P2P edit doesn't mean it is ok even if it goes through and gets paid.

If you have another total joint guy in your group or another physician who is more of a coding advocate, sometimes they can help. I used to lean on some of the other physicians to help when we had situations like this in my past experience.
 
Your surgeon is 100% incorrect.
Bone graft from the excised humeral head is NOT separately billable.
It is not from a different incision. A TSA cannot be performed without removing the humeral head and so that bone graft being available is an integral part of the procedure.

The guidance that this is even somewhat okay came from an ASES webinar that went completely against the coding guidance of the ASES Coding Reps, the AAOS, KZA, and the clear guidance of both CMS/CPT and CMS. When this was brought to the attention of ASES leadership, they removed the webinar and have since corrected their guidance.

The GSD notes that for 23472 only graft harvest from a distant site and a separate skin or fascial incision is separately reportable.

And the fact that it has "previously been accepted" doesn't make it right.
If he persists, he is free to submit the query to AAOS' Coding Coverage and Reimbursement Committee, where he will get exactly the same answer. Why? Because we've addressed it before.
 
amyjph said:
If you are exclusively coding orthopedics and don't have any of those references you mentioned, you are really working with a big disadvantage. Are your surgeries at least run through an RVU and NCCI edit checker before billing?
Has anyone taken a look at data analytics on denials/rejections and/or take-backs for these cases? Has the provider gotten any audit or other medical record documentation requests? Do plans often ask for records like in a pre-pay scenario before paying claims? If it is 7-10cc I guess you could call that small however, you still can't code that when it is taken from the same site/humeral head which was removed for the TSA. What else is he trying to unbundle? Just because there is no P2P edit doesn't mean it is ok even if it goes through and gets paid.

If you have another total joint guy in your group or another physician who is more of a coding advocate, sometimes they can help. I used to lean on some of the other physicians to help when we had situations like this in my past experience.
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Hi Amy, I work for a very, very large national hospital system, and they provide us with Codify so that we do check NCCI edits and whatever information available on the CPT codes. As strictly coders, we have no concern about RVUs, only correct coding. Of course, some of the physicians are extremely RVU driven. In our coding department we have many different specialties however each one is handled by one team coding strictly for that specialty. Our Team is Ortho, and we code for over 100 Orthopedists plus this new group of 30 plus additional providers that we have recently acquired and have taken over their coding. Apparently with their previous coding, however that was done, they were able to code whatever they wanted - bundled procedures, open codes for arthroscopic procedures, codes not supported by documentation, etc. There have never been issues with the coding for our other providers until this group, who insists on adding their codes and wanting notification when they need to be corrected. This is why I need to verify with supporting documentation the correct coding of this CPT code. As far as audits and data analytics, etc. we have a number of departments that handle that. As a new group of doctors however they have not generated enough revenue with us at this time for a true audit and all of their coding discretions would have been prior to joining us. And to answer your question about another total joint guy - we have many, many joint guys of all different types! This one just thinks what he does is more special!! :cool: Thanks for your help!
 
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