Bone Cyst Tibia and Fibula

Question:

Our surgeon documented an excision and curettage of a bone cyst from the tibia and the fibula near the ankle joint. I am looking at CPT code 27635 and wondering if this is the correct code and if I report it once or twice.

Answer:

CPT code 27635 (Excision or curettage of bone cyst or benign tumor, tibia or fibula;) appears to be the correct code based on your inquiry. We are not able to confirm the actual CPT code without reviewing the operative note. The code descriptor reads “tibia or fibula”; this means the code is correct whether the bone cyst or benign tumor is on the tibia or the fibula (meaning there are not different codes for each location). While CPT says “or” meaning it could be reported more than one time, CMS has a MUE (mutually exclusive edit) in place limiting the code to one unit, citing a Date of Service (DOS) Clinical Edit (3) and based on CMS policy. This edit became effective January 1, 2021.

The following citation is extracted from CMS National Correct Coding InitiativePolicy Guidelines(page 38 1/28/2021):

“MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks.” MUEs assigned an MAI of “3” are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.”

Additional information on MUE’s may be found in the above link.

*This response is based on the best information available as of 05/13/21.

Separate Procedure Billing

Question:

I am new to coding and have a Question:. I remember studying about “separate procedures” and have my first operative note that includes a code that has this in the code definition. The surgeon performed a diagnostic arthroscopy (CPT code 29870) and confirmed the meniscal tear prior to proceeding with the planned meniscectomy and chondroplasty.

Does this separate procedure mean we can bill it in addition the meniscectomy CPT code, or it is included?

Answer:

Thanks for your Question:. CPT code 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) is as you say a ‘separate procedure’ designated code. In your scenario, this means that the diagnostic arthroscopy is inclusive to the meniscectomy performed on the same knee during the same operative session and is not separately reportable. If the surgeon had performed a left knee meniscectomy and a right knee diagnostic arthroscopy, both services would be reportable with RT and LT modifiers to differentiate them.

*This response is based on the best information available as of 04/29/21.

Medication Documentation

Question:

We are switching to a new EHR system. We have not always had great compliance with our providers documenting what we feel needs to be documented so we want to do it right. Are you able to advise what should be included in the medical record when the provider administers medications, for example intra-articularly?

Answer:

Thank you for your Question:. Like you, we find in audits that providers do not always include the basic information required to select and submit a HCPCS code for medications. In Orthopaedics, this is most commonly related to injections to tendons, nerves, joints to name a few anatomic locations.

Documentation should include the medication name, dosage (mg or mg/ml), the route of administration and location (e.g. flexor tendon sheath, tendon insertion site, left shoulder subacromial space). In Orthopaedics, for example, J3301 describes Triamcinolone Acetonide, 10 Mg/ml. Vials for this medication commonly are available in 40 mg/ml or 80 mg/ml vial concentrations. If the physician states that “2ml” was injected into the right knee joint, it is not known if 80 mg or 160 mg was injected without the concentration. The impact, other than recording the incorrect dose, may result in incorrect reporting of the J code. 1 milliliter of Triamcinolone 40 mg/ml is reported as J3301 x 4 units; 1 ml of Triamcinolone 80 mg/ml is reported as J3301 x 8. In the example of “2ml”, the variance would be J3301 x 8 versus J3301 x 16.

Also include documentation of patient tolerance or reactions to the medications and instructions for follow-up monitoring. Don’t forget to record include wastage of drugs as appropriate and instructed by the payor, using modifier JW.

*This response is based on the best information available as of 03/18/21.

Is a Lateral Retinacular Release Separately Billable?

Question:

Our surgeon performed a reconstruction of a patella dislocation and also did an arthrotomy of the knee with a lateral retinacular release. Our surgeon wants to report 27420 and 27425. When I look at the NCCI edits, I see there is an edit between the two codes. Am I allowed to add a modifier 59 to CPT® code 27425 to indicate this is a distinct separate service?

Answer:

Thank you for your inquiry. Let’s start by taking a look at the CPT® code definitions.

27420 Reconstruction of dislocating patella; (eg, Hauser type procedure)27425 Lateral retinacular release, open

To answer, your Question:, the answer is “no, the lateral retinacular release is inclusive to CPT® code 27420 for the reconstruction of the patellar dislocation.

Why? Let’s take a look at the AAOS Global Service Data Guide for CPT® code 27420.

The following is an excerpt of procedures that are considered ‘inclusive” to CPT® code 27420 when performed during the same operative session.

• osteotomy (eg, 27457)
• arthrotomy of knee (eg, 27310, 27330, 27331)
• release of lateral retinaculum (eg, 27425)
• internal fixation
• chondroplasty of patella (eg, 27437)
• diagnostic arthroscopy of knee (eg, 29870)

You already note the NCCI edit between 27420 and 27425; adding modifier 59 to CPT® code 27425 represents incorrect coding.

*This response is based on the best information available as of 12/03/20.

SI Joint Injection Help

Question:

My physician performed an SI joint injection in the ASC under ultrasound guidance and wants to bill 27096 and 76942. Is this correct? The description of the codes say imaging is included.

Answer:

No, this is not correct; you are correct to catch the inclusion of the imaging statement.

CPT code 27096 is defined as includingfluoroscopic or CT guidance, but not ultrasound (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed).

Per CPT guidelines, if ultrasound is used instead of fluoroscopy or CT, report a trigger point injection code 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) and 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). CPT code 20552 is reported one time, whether the procedure is performed as a unilateral or bilateral procedure. Remember, CPT code 76942 has a professional and technical component; in the ASC setting you will append modifier 26 assuming the procedure note includes the required documentation for US guidance.

In answer to your question based on the ASC place of service, assuming documentation and medical necessity are present, the correct codes are:2055276942-26

If the procedure is performed in the office setting and you own the equipment, you may report 76942 without a modifier if the documentation supports the service.

Note: Some payor policies may deny payment of the US guidance ( CPT code 76942) with CPT code 20552.

*This response is based on the best information available as of 10/29/20.

Subacromial Decompression (29826)

Question:

Our surgeon frequently documents in the procedure title that an arthroscopic subacromial decompression was performed.  We are billing 29826 and are receiving denials from one particular payor stating that the documentation does not support the service.  I am looking at the operative notes associated with these denials and see that in none of the cases did the surgeon document any bony work. Is this required to report this code?

Answer:

Thank you for sharing your experience.  We heard of these denials years ago, so we appreciate  your sharing this information that a payor is again looking  at this code for supportive documentation.  To answer your Question:, yes, CPT code 29826 includes work on the acromion.

Note in the CPT code description, partial acromioplasty is listed as part of the procedure;  this is the ‘bony work’ in your inquiry.

29826  Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)

Soft tissue work alone does not meet the definition of this CPT code. Typically, we see documentation similar to ‘an acromioplasty was performed  and reshaped to a type 1 acromion.’ This type of documentation will support the required work for the acromioplasty.  Removal of osteophytes or co-planing of the acromion does not support the partial acromioplasty requirement.

*This response is based on the best information available as of 10/15/20.