E&M and Injections: Is this billable?

Question:

We have a new patient presenting for evaluation of new elbow pain following a fall.  The provider documented a full history, exam, ordered and interpreted X-Rays.  Following this evaluation and discussion with the patient, they agreed the best option was to aspirate and inject the joint.  The procedure note documents the aspiration and injection of a corticosteroid. Does this meet the significant, separate service rules to report both the E&M and the aspiration/injection?  

Answer:

Based on the description of the encounter, KZA recommends reporting the E&M-25 and the injection code (20605) and the J code for the drug.  Remember, Medicare requires the JW or JZ modifiers effective July 1, 2023, if the medication was obtained from single-dose package.   Review with your private payors if they are following the same requirement.   

Rationale:  

New problem  

The intent of the visit was not the injection.  

Full E&M service performed.  

Joint decision making with patient on options and to proceed with minor procedure.  

*This response is based on the best information available as of 1/30/25.

Co-Planing of AC Joint

Question:

Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?  

Answer:

Thank you for your inquiry. Co-planing of the AC joint/distal clavicle does not support a distal clavicle resection. To report CPT code 29824, the documentation should include that the surgeon performed a “resection of the distal clavicle.” If the surgeon documents the amount, it should be based on the surgeon’s assessment of the amount of bone excised. 

In the early 2000’s the AAOS clarified the amount in the Global Service Data Guide that the amount of distal clavicle resection did have to be 1.0 cm. The AMA published a correction recently saying that the CPT code does not include the requirement of a specific bone-excision measurement of 1.0. This is consistent with the AAOS’s early position that the amount excised must be specific to the patient anatomy, physical size, and other factors. However, co-planing, removal of osteophytes, removal of bone spurs does not support a distal clavicle resection.  

*This response is based on the best information available as of 1/16/25.

Modifier 80 vs 82

Question:

What is the difference between modifier 80 and modifier 82 when a physician is acting as an assistant during surgery?

Answer:

While both modifier 80 and modifier 82 are used when a physician is actively participating as an assistant to a primary surgeon during a surgical procedure, modifier 82 is used in teaching or university hospitals that have approved Graduate Medical Education (GME) programs for Residents. In these teaching hospitals, there must be documentation indicating that no qualified resident was available to assist, to allow for another physician to act as the assistant surgeon, and then modifier 82 is appended to that assistant surgeon.

*This response is based on the best information available as of 1/2/25.

Periprosthetic fractures ICD-10

Question:

I'm new to coding ortho and I am very confused on how to code periprosthetic fractures. I was under the impression that only one ICD-10 was required for this type of fracture (M97.x). What am I missing?

Answer:

There is a category of codes in ICD-10, specific to Periprosthetic fractures around internal prosthetic joints, and the category is M97. When referring to the tabular section of ICD-10, under M97 category there is an instructional note which states the following: code first, if known, the specific type and cause of the fracture. That being said, if the documentation reflects the site and type of fracture while also identifying this as a periprosthetic fracture around an internal prosthetic joint, you will assign the primary ICD-10 code for the known fracture, followed by ICD-10 from M97 series to identify the periprosthetic fracture for the specific joint. 

Example: Displaced comminuted periprosthetic fracture of the proximal shaft of the right femur, patient status post right total hip replacement. 

ICD-10 codes: 

1) S72.351A 

2) M97.01XA 

Let's take this one step further, according to ICD-10, if you have a periprosthetic fracture around a prosthetic joint in which there is no specific code, then you would report M97.8XX-, and then use an additional ICD-10 code to identify the joint Z96.6-. The ICD 10 instructions for M97 instruct to code first, if known, the specific type and cause (e.g. pathologic or traumatic). If you read on to M97.8, there are additional instructions to also report the appropriate joint (Z96.6-). As you can see, the instructions and hierarchy are a bit different when there is a specific joint arthroplasty code versus not. 

Example: Displaced comminuted periprosthetic fracture of the right distal radial shaft, patient status post right wrist arthroplasty. 

ICD-10 codes: 

1) S52.351A 

2) M97.8XXA 

3) Z96.631 

*This response is based on the best information available as of 12/19/24.

Percutaneous Fracture Fixation

Question:

Our surgeon performed a closed reduction of a medial malleolar fracture with percutaneous fixation. There is no documentation of an open reduction, and we are unsure how to report this procedure.  

Answer:

Percutaneous fixation of a medial malleolar fracture is reported with an unlisted code, 27899. Work with your surgeon to identify a comparison code; one option is CPT code 27762 (Closed treatment of medial malleolus fracture with manipulation, with or without skin or skeletal traction).  

*This response is based on the best information available as of 12/5/24.

Conversion of UKA to TKR

Question:

I took a significant leave from coding orthopedics; now, I'm back in the trenches coding for ortho. Has the coding recommendation for revising a unicompartmental knee arthroplasty to a total knee replacement changed? I'm confused; our surgeons gave me an AAOS Now Article from 2023, and I have the CPT Assistant article from 2013. Can you please advise?  

Answer:

In the hip section of CPT, we have code 27132 (Conversion of a previously open procedure to total hip arthroplasty). Unfortunately, no code exists in the knee section of the CPT book. 

In June 2023, an AAOS Now article was published that addressed this question with two different coding directions. 

· The first coding option outlined, if the conversion is simple with primary implants, is to report CPT 27447 and append modifier 22 for the increased work due to the altered field. 

· The second coding option outlined states is to report code 27487 if bony defects require augments or stems. 

KZA understands that the June 2023 article was superseded by a revised article removing the published recommendation. The revised article can be found on the AAOS website in the Archives section for June 2023. 

However, a CPT Assistant addressed this question in July 2013, stating to report this coding scenario with CPT 27487 and append modifier 52 (reduced services). 

KZA understands why you are confused! As you see, there are now two different sources with three different coding recommendations, which leaves a coder to wonder which coding guidance to follow when having to code a conversion of a UKA to a TKR. It's not a great spot for a coder to be in when you have a case to code! While the CPT Assistant from July 2013 is older, KZA recommends following the AMA CPT article until the AMA publishes an updated article. A conversion of UKA to a TKR/TKA is 27487-52. 

*This response is based on the best information available as of 11/14/24.