Wiki help with hip surgery coding

[Jennifer17]

core decompression left hip with iliac stem transfer and the doctor coded it as 26992, 38220, and 38241

insurance only paid on the 38220 and says for 26992 that the facility type is restricted for procedure under provider contract - it was 22 outpatient

any advise?

Thanks

 

[mdgiddens]

2017 denials for cpt 38220

I am getting denials for CPT 38220, bone marrow aspirate, for graft performed during spine fusion on 2017 claims. I understand that the code changed as of 2018 to 20939, but up until then we could append modifier 59 if it was removed through separate incision..e.g iliac crest. is there any information that states claims with 38220 would be denied prior to 2018 with this code, before I go through the lengthy appeals process?

 

[AlanPechacek]

If I interpret your query correctly, your physician treated Avascular Necrosis of the Femoral Head with Core Decompression, then added Bone Marrow Derived Stem Cells as a "Graft" into the Femoral Head to fill the space/defect/void resulting from the drilling into the diseased region in the Femoral Head. For what it is worth, there is no CPT Code that really covers this procedure. In fact the treatment of AVN of the femoral head or any other location is not covered in CPT. The 26992 code: Incision of Bone Cortex, Hip &/or Pelvis, doesn't really fill the bill, as it appears to apply to infectious disorders of bone as a form of I&D. I would not consider Core Decompression of the Femoral Head to be an I&D procedure. Probably the "best" code for this procedure is 27299: Unlisted procedure, hip or pelvis. The problem then is what procedure to "pair" it with. The "best" I can find is 27235: Percutaneous Skeletal Fixation of a Femoral Neck Fracture, which in many respects is like Core Decompression, except that no fixation is inserted. Another, but less close procedure is 27170: Bone Graft of Femoral Head (Neck, etc. proximal femur) which includes obtaining the bone graft. But, this code is probably more directed towards treating a non-union of a fracture of this region (proximal femur) than AVN, and it uses a bone graft rather than bone marrow derived stem cells. Of these two, I would probably go with 27235.
As for the Bone Marrow derived Stem Cells, the "best" code for this is 38232: Bone Marrow harvesting for transplantation, autologous, as this is what your physician did. This is different from 38220, which applies to Diagnostic Bone Marrow Aspiration, but not transplantation, and 38241, which is for Blood Derived cells Transplantation by Infusion, which is not the same as bone marrow derived Stem Cells.

Hopefully this discussion helps.

Respectfully submitted, Alan Pechacek, M.D.