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.

Laminoplasty Scenarios

Question:

In our spine practice, we often see different laminoplasty scenarios for coding. Is it ever appropriate to report decompression in addition to laminoplasty (63051)? Hope you don’t mind, but I have included a couple of commonly seen laminoplasty scenarios from our practice that we are eager for KZA’s opinion. 

Scenario #1 Our surgeons wish to bill 63051 for laminoplasty (C4-C6) and 63020 & 63035 for foraminotomies (C4/5 & C5/6) because they say it's a significant amount of work. We struggle with this one, is this appropriate? 

Scenario #2 Laminoplasty performed from C4-C6, and decompression performed at C2/3?   

Scenario #3 Laminoplasty performed from C4-C6 with partial laminectomies performed at C3 & C7.  

Answer:

 Great questions and scenarios!  Most importantly, laminoplasty codes should not be reported with arthrodesis, instrumentation, decompression, or osteoplastic reconstruction at the same vertebral segment.  Meaning, if the laminoplasty is from C4-C6 and the foraminotomies are performed at C4/C5 & C5/C6, only CPT 63051 is reported.    

Scenario #1 CPT 63051 is only reportable.  

 * KZA is not addressing the accuracy of CPT code 63020/63035 for a foraminotomy in non-related cases. 

Scenario #2 CPT 63051 & 63045-59 (distinct separate procedure) or XS modifier, as directed by your payor to reflect decompression, was performed at a separate level from laminoplasty.    

Scenario #3 Only CPT 63051 is reportable, the partial laminectomies above and below the laminoplasty are considered included to complete the laminoplasty. 

*This response is based on the best information available as of 10/31/24.

Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?  

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Fall Risk Prevention Program: Part 2

Question:

We read and received your recent Coding Coach on the Fall Risk Prevention Program and directive to report Category II CPT codes for this service. We have a follow-up question.  Why would we not be able to report CPT code 97750 for this service, and can this code be billed incident- to the physician if the MA performs the work?   

Answer:

Per CPT coding guidelines, many parameters are associated with reporting CPT code 97750. CPT code 97750 is not used for a MIPS tracking code. Reporting this code requires that the work be performed by an MD, DO, or PT. An MA may not perform the work associated with this code and bill incident - to, as an MA is not a Qualified Healthcare Professional (QHP). 

*This response is based on the best information available as of 9/16/24.