Wiki CPT Code 27446 & 27430 help!!

[Diana2032]

Good afternoon All,

I was wondering if any of you can help me, my provider keeps submitting this cpt code combo: 27446 (partial knee replacement) and 27430 (quadricepsplasty). I have read articles on line and all of them say "no" you cannot bill these codes together but there's no information as to why you cannot bill that way. I have asked my provider to stop submitting these codes furthermore, I explained to him that if the only diagnosis he is documenting is knee osteoarthritis without any evidence of knee contracture these two codes cannot be billed together. His response was "there is no cci edits I should be able to bill those codes". Please someone clarify this for me.

Thank you,

 

[Orthocoderpgu]

Quadricepsplasy still needs to be supported and is not a normal part of a replacement

Even though 27446 & 27430 do not hit an edit, that does not mean that both can be billed. Before any code is billed there must be "Medical Necessity". Per AAOS a quadricepsplasty is not a normal part of performing 27446. So this means that before 27430 can be billed (alone or with any other code) there must be a documented medical reason for it. Without it, the insurance should not be paying for it and if this is discovered in an audit, especially an outside audit (say from the insurance company) this would be repaid and if they can show that this is a normal "pattern" of billing, that opens your physician up to fraud charges. I don't think your physician has thought through or may not be aware of the position that he is putting himself in. I worked for major insurance companies and they have people review claims that have already been processed. So if this has been paid, this could lead to an investigation. I would document specifically the dates and times that you have gone over this with him to protect yourself. Do it again if you need to.