Question Elbow surgery codes

[jdibble]

I appreciate all the help I can get on this one with the reasoning as to how it would be coded.

My surgeon did an arthroscopic elbow surgery and gave me a list of codes he believes should be billed. The surgery was for an ORIF fracture repair, an ulnar nerve neuroplasty and contractor release. The codes he wants to bill are 24575, 29838, 24149. I have explained that he could not use 24149 as that part of the surgery was done arthroscopically. He is insisting that the work that he did within the elbow arthroscopically is more extensive than the work represented by 29838 and 29836 and that 24149 represents the work better. He can get very stubborn about how his surgeries get billed as he feels his work is not represented correctly with the RVUs provided by the codes we suggested. His response to the use of the arthroscopic codes is that he feels "he is undercoding for his work as he is one of the only surgeons in [our state] that performs this surgery," which he states was "an osteocapsular arthroplasty that requires removal of heterotopic bone and resection of part of the joint, complete synovectomy and contracture release with a capsular removal". Could someone please review his note and tell me what codes you would use? Would the arthroscopic codes be sufficient or would an unlisted code be needed?

Procedures
Panel 1 Procedures: Left elbow arthroscopy with heterotopic ossification excision, plate removal, open reduction internal fixation of lateral condyle and all indicated procedures (L)

Ulnar nerve in situ decompression 64718
Tourniquet was inflated to 250 mmHg pressure.
A longitudinal medial-sided incision was posteromedially over 3cm. The skin and subcuticular tissue were dissected sharply with a #15 blade scalpel. Dissection was carried sharply down to the underlying fascia. I then dissected the ulnar nerve distally to the first motor branch to the flexor carpi ulnaris and proximally to the ligament of Struthers. There was no evidence of subluxation through a flexion-extension arc. The nerve was compressed at the cubital tunnel and distally into the flexor carpi ulnaris..

ORIF lateral condyle nonunion
Next, I created a lateral incision centered over the lateral epicondyle and lateral column. Skin subcuticular tissues were dissected sharply with a fresh 15 blade scalpels.
The lateral condyle nonunion was exposed. It was still ligament and some tendinous attachments to the forearm present. I used a 4 mm bur to bur the nonunion site on both sides of the fracture. A locking whipstitch was placed through the ligament and tendon and a 2 mm drill hole was drilled through the fragment which was nonunited. Then under fluoroscopic guidance I drilled with a guide pin introduced a cortical button on the far cortex anteromedially. The button was flipped in the construct was tensioned compressing the fracture. I then oversewed this with 2. FiberWire and 1. Vicryl. This improved the contour of the elbow and also compressed and repaired the nonunited fracture.

Finally, I established anteromedial, anterolateral, posterior central and posterolateral arthroscopy portals and performed a diagnostic arthroscopy with the findings noted above. I resected the anterior coronoid to improve elbow flexion. Complete contracture release but with a performed. Similarly I released the shoe posteriorly and performed a complete synovectomy and capsulectomy both anteriorly and posteriorly. There was diffuse arthrofibrosis throughout. I also dissected down along the radial neck and released a portion of the annular ligament to help increase pronation.

I then removed all of our arthroscopic equipment and fluid, placed a nylon suture in each portal.
Similarly the open incisions were closed with a layered closure and subcuticular sutures backed up with nylon sutures.


Thank you for any and all help!
Jodi

 

[NRaizman]

You can code for ORIF and cubital tunnel release.

29838 is the only other code you can code. I'd consider a -22 modifier, BUT the operative note is so weak and crappy it does not justify a -22 modifier. Your surgeon is leaving money on the table through inadequate documentation. If he wants to get more reimbursement for this procedure, then he has to document thoroughly its difficulty and how it is way more intense and time consuming than a standard "extensive debridement" which is NOT IN ANY WAY done. 29838 carries 80 minutes of intraoperative time, so your surgeon would need to be pretty clear that his time was well in excess of that or that the level of complexity and difficulty warranted it. That is not done here.

You cannot -ever- use an open code for an arthroscopic procedure, so 24149 is out, and it would be improper to use an unlisted, as the work is entirely encompassed by 29838.
I am also, as an experienced elbow surgeon, totally unimpressed with the surgeon's claims of being one of the only people in the state who performs complex elbow arthroscopy.

 

[jdibble]

You can code for ORIF and cubital tunnel release.

29838 is the only other code you can code. I'd consider a -22 modifier, BUT the operative note is so weak and crappy it does not justify a -22 modifier. Your surgeon is leaving money on the table through inadequate documentation. If he wants to get more reimbursement for this procedure, then he has to document thoroughly its difficulty and how it is way more intense and time consuming than a standard "extensive debridement" which is NOT IN ANY WAY done. 29838 carries 80 minutes of intraoperative time, so your surgeon would need to be pretty clear that his time was well in excess of that or that the level of complexity and difficulty warranted it. That is not done here.

You cannot -ever- use an open code for an arthroscopic procedure, so 24149 is out, and it would be improper to use an unlisted, as the work is entirely encompassed by 29838.
I am also, as an experienced elbow surgeon, totally unimpressed with the surgeon's claims of being one of the only people in the state who performs complex elbow arthroscopy.

Thank you very much for your help. I appreciate your response. Hopefully this will help with proving my point with this doctor as well as my directors so that we can use the correct codes and also convince them that he needs to initiate modifications to his documentation on future surgeries to support what he believes he did!