When is it OK to bill a Bakers Cyst removal (27345) with a Total Knee Arthroplasty (27447)? The physician documented that the Cyst was removed through a separate capsular incision, and is insisting that it should be paid in addition to the TKA.
In order to qualify for a modifier to break the edit, the Baker's cyst would need to be performed on the contralateral knee. I don't see it being covered on the ipsilateral knee even though it was performed via a separate incision. Look at the payer as well. If they generally follow the NCCI edits (vs AAOS) such as BX or UHC, you will have an uphill battle and probably not talk them into actually covering the procedure.
I disagree that your surgeon cannot be compensated for both the TKA and the Cyst removal. Baker's Cysts are not rare in adults, and when they occur, they are felt to result from inflammation of the joint from some intra-articular problem (in this case Arthritis) that causes excess joint fluid formation. When the joint gets too full of fluid it can "flow" into the cyst behind the joint. But it seems to be only a one way flow system in that the fluid flows from the joint into the cyst, but doesn't flow back even when the joint inflammation subsides. Consequently, the cyst remains and retains its fluid. If it is large &/or tight enough to cause its own symptoms and problem for the patient, then its treatment may be warranted in addition to the Arthritis of the joint. In other words, the patient has two problems to be treated surgically. However, the documentation needs to support all of this. The Office Notes before surgery need to identify and diagnosis code both the arthritis and the cyst as being present and needing treatment. The Preop Diagnosis should indicate this as well, and the Op Permit should include the Arthroplasty and Cyst Removal as planned procedures. The Postoperative Diagnosis should have both diagnoses listed, and Description of the Procedure should address and document that both were done. I do not think that the cyst removal is an "integral part" of a TKA, and should be considered an additional procedure for which there should be additional charges and compensation. A Modifier would need to be applied to the cyst removal as the TKA was the primary procedure. If both were done through the same skin incision, but with a separate "capsular incision" then I would use Modifier 51 for Multiple Procedure. The alternative to this would be Modifier 22 for Increased Procedural Services, but I would lean towards 51. If a completely separate skin incision were utilized, making it a completely "additional" procedure, then one of the Modifier 59 variants would probably apply.
Hopefully this helps.
Respectfully submitted, Alan Pechacek, M.D.