Arthrex, Inc.
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FAQs


1.  What is the definition of an implant?

 

2. How can I view the latest CPT updates? 


3. When a patient has degenerative joint disease of both knees, what is the correct code assignment? 


4. ICD-9 727.61 is for a complete tear/rupture of Rotator Cuff. If it was a partial tear, it would be 840.4. What then is appropriate for Hill-Sachs and Bankart? 


5. Some private payers are now bundling 29807 and 29806. We use 59 modifier and differential diagnosis for acromioplasty. CCI edit states modifier is allowed with 29826. How do we account for subacromial decompression? 


6. What CPT codes can be used for "Repair of distal tibiofibular syndesmosis injury"? 


7. If the OATS procedure is performed on the medial femoral condyle, lateral femoral condyle AND the trochlea is the procedural code billed 3 times for each compartment/site or just once for all autograft and 3 sites? 


8. The rotator cuff tear ICD-9 codes are confusing. If I understand correctly, 840.X are for acute traumatic tears but what about 727.61 and 726.10?  A chronic RCR of, say, a tear of the supraspinatis, is it O.K. to use 840.6? 727.61 says it's for "complete" rupture; would that be ok for just a chronic partial tear of the supraspinatus? 


9. Where can we find a thorough explanation of the latest knee codes? 


 

1. What is the official definition of an implant?


Our main reimbursement page contains a link to a list of the Arthrex products which fit into this category. Medicare implemented its current system to pay hospitals for services provided in hospital outpatient departments. Known as OPPS (Outpatient Prospective Payment System), this system includes certain billing codes called "C" codes, or "transitional pass-through" codes. Medicare created over 90 such categories of devices, each category with its own specific "C" code. If a provider uses a device that fits a pass-through category, they include the appropriate C-code on their bill to Medicare, and receive an additional payment.

Most fixation devices fell into the original pass-through categories. The operational definition for C-1713 is "Anchor/Screw for opposing bone-to-bone or soft tissue to bone (implantable)"1 Devices eligible for pass-through payments are further defined as, "They are considered reasonable and necessary for the diagnosis and treatment of an illness or injury or to improve the functioning of a malformed body part. They are an integral and subordinate part of the procedure performed, and are used for one patient only, are single use, come in contact with human tissue, and are surgically implanted or inserted whether or not they remain with the patient when the patient is released. They are not equipment, instruments, apparatuses, implements, or such items for which depreciation and financing expenses are recovered."

1) Medicare Claims Processing Manual, transmittal 585 6.30.2005     2) CMS Pub. 100-04, transmittal 403 12.17.2005  

2. How can I view the latest CPT updates?


As of January 1 and July 1 in a given CPT® cycle, and after Editorial Panel approval, the newly added Category III CPT codes will be made available on a semi-annual (twice a year) basis via electronic distribution on this web site. The full set of Category III codes will be included in the next published edition for that CPT cycle. 

http://www.ama-assn.org/ama/pub/category/3885.html

3. When a patient has degenerative joint disease of both knees, what is the correct code assignment?


Assign code 715.36 (Osteoarthrosis, localized, not specified whether primary or secondary, for bilateral degenerative joint disease, knee). In the Tabular List (Volume 1), under category 715 (Osteoarthrosis and allied disorders), an instructional note can be found:

"Note: Localized, in the subcategories below, includes bilateral involvement of the same site." 

This note should be interpreted to mean that bilateral involvement is included in the fifth digit for that site. Furthermore, when the degenerative joint disease affects only one site, but is not identified as primary or secondary, it is coded to 715.3x (Osteoarthrosis, localized, not specified whether primary or secondary). If it involves more than one site but is not specified as generalized, assign code 715.8x (Osteoarthrosis involving, or with mention of, more than one site but not specified as generalized).
 
 

4. If ICD-9 727.61 is for a complete tear/rupture of Rotator Cuff. If it was a partial tear, it would be 840.4. What then is appropriate for Hill-Sachs and Bankart?


718.01 and 905.6 together for Hill-Sachs and 719.81 for Bankart.     

5. Some private payers are now bundling 29807 and 29806. We use 59 modifier and differential diagnosis for acromioplasty. CCI edit states modifier is allowed with 29826. How do we account for Subacromial decompression?


AAOS Coding, Coverage and Reimbursement Committee recognizes three separate and distinct regions of the shoulder, the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space. In order to support the extensive or complete scope codes you must be in two of the three. Append modifier -59 to 29826 to acknowledge a separate region of the shoulder and that acromioplasty with subacromial decompression was documented in the operative report. They are bundled according to CCI. They can be unbundled if justified. The AAOS global states you can report only if SLAP Lesion repair is a Type 2 or Type 4, so your documentation must support the type of lesion being repaired. If an appeal is needed, use the AAOS brief. 
 

6. What CPT codes can be used for "Repair of distal tibiofibular syndesmosis injury"?


Best for Weber B and C type Fx, consider 27814 (Open treatment of bimalleolar ankle fracture, with or without internal or external fixation) and 27829 (Open treatment of distal tibiofibular joint (syndesmosis) disruption, with or without internal or external fixation.) There is no code for repair of a nonunion/malunion bimalleolar fracture. Some have suggested 27725 (Repair of nonunion or malunion, tibia; without graft, (e.g., compression technique) - by synostosis, with fibula, any method?

   

7. If the OATS procedure is performed on the medial femoral condyle, lateral femoral condyle AND the trochlea would you bill the procedural code 3 times for each compartment/site or just once for all autograft and 3 sites?


Report by compartment, not by number of grafts.   

8. The rotator cuff tear ICD-9 codes are confusing. If I understand correctly, 840.X are for acute traumatic tears but what about 727.61 and 726.10? A chronic RCR of, say, a tear of the supraspinatis, is it O.K. to use 840.6? 727.61 says it's for "complete" rupture; would that be ok for just a chronic partial tear of the supraspinatus?


No. Use 727.61 for degenerative RC tear since it is NOT a complete rupture.   

9. We are looking for a thorough explanation of the latest Knee codes.


Five recent Knee procedure codes. (Excerpted, AAOS Bulletin)     By Margie Scalley Vaught, CPC, CPC-H, CCS-P, ASC-OR; M. Bradford Henley, MD; William Beach, MD; and Mel Friedman, MD 
 
As mentioned in the April Bulletin, five new knee procedure codes were added to the Current Procedural Terminology (CPT) in 2005. This column will cover the new procedure codes as well as coding for minimally invasive joint replacement procedures. 
   

Meniscal transplant


The new code for arthroscopic meniscal transplantation is 29868. According to the AAOS Global Service Data Book (GSD), this code includes the following procedures: diagnostic arthroscopy; lavage and/or drainage; lysis of adhesions; and minor synovectomy for visualization.   

The GSD also states that removal of loose bodies, arthroscopic chondroplasty (in a different compartment) and arthroscopic abrasionplasty can be separately reported as they are considered excluded. In general, the AAOS editorial panel for the GSD considers removal of loose bodies to be a separately reportable service when the loose bodies are of sufficient size that they require removal through a separate incision or when they are too large (e.g. >5mm) to flow out through an arthroscopic sheath. Because most payers require that medical necessity be established preoperatively, the specific diagnosis of "loose body(ies)" should be made prior to preauthorization.  

However, the CPT Changes for 2005: An Insider's View says that code 29868 includes all of the following actions: preparation of the defective area; removal of the damaged portion of meniscus; creation of tibial tunnels or a bone trough as stabilizing structures for the implant; insertion of the meniscal graft via arthrotomy; joint exploration; synovial biopsy; lavage, drainage and removal of "loose bodies" synovectomy; meniscectomy; medial and lateral meniscus repair; and lysis of adhesions.   

Before the CPT Changes for 2005 was printed, the intention was that code 29868 would include 29881 (meniscectomy), 29877 (chondroplasty) and 29874 (loose body removal) when performed in the same compartment as the meniscal transplant, but not when they were performed in the other compartments. However, as the result of a typographical error, the printed edition states that 29881, 29874 and 29877 cannot be listed and reimbursed with code 29868.   

The AAOS Coding, Coverage and Reimbursement Committee applied for and has been granted a change in 2006, thereby correcting this error. A parenthetical note in the 2006 manual will confirm that separate compartment coding is permitted.   

The CPT Coding Manual 2005 also includes several cross references that address bundling issues. Under the guidelines, procedures such as diagnostic scope (29870), lavage (29871), synovectomy (29875), removal of loose body(ies)(29874), meniscectomy (29880 and 29881), meniscus repairs (29882 and 29883) and lysis of adhesions (29884) are NOT to be reported separately when these procedures are performed at the same session and in the same compartments. 
  

Arthroscopic mosaicplasty (knee)


Two new arthroscopic codes were added for osteochondral grafting - one for an autograft and the other for an allograft. Code 29866 covers "Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft)." Code 29867 covers "Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty)."   

According to the AAOS GSD, use of codes 29866 or 29867 would include diagnostic arthroscopy, lavage and/or drainage, lysis of adhesions and minor synovectomy for visualization. However, removal of loose bodies, arthroscopic chondroplasty of a different compartment and arthroscopic abrasioplasty are excluded under these codes.

The CPT's view on bundling for osteochondral grafting is covered in CPT Changes for 2005: An Insider's View, which states:  

"Code 29866 was established to report scope osteochondral autograft harvest and implantation of femoral peripheral cartilage in the knee. As this procedure typically requires the placement of multiple grafts, code 29866 is reported one time per procedure, regardless of the number of grafts obtained and inserted. Harvest of the autograft is NOT reported separately in addition to 29866, as acquisition of the graft is inherent in the scope of osteochondral autograft implantation.  

"Code 29867 was established to report the performance of scope repair of lesions of the femoral condyle with placement of osteochondral allograft arthroscopic. An instructional note following 29867 also indicates that open code 27415 is NOT appropriately reported in addition to the scope procedure at the same session."

The CPT Coding Manual 2005 includes several cross references on bundling issues. Based on this manual, the following procedures would be considered bundled when performed in the same compartment with code 29866: diagnostic scope (29870), lavage (29871), synovectomy (29875), removal of loose body(ies)(29874), chondroplasty (29877), abrasion chondroplasty (29879), drilling of osteochondritis dissecans (29885-29887) and lysis of adhesions (29884).   

Originally, 29877 and 29874 were to be included when performed in the same compartment but not if performed in a different compartment. A typographical error stated 29874 and 29877 couldn't be listed and reimbursed. The AAOS Coding, Coverage and Reimbursement Committee applied for and has been granted a change in 2006, to correct this error. The AMA will note that separate compartment coding can be performed in the 2006 manual.   

Many insurance companies have carrier-specific polices covering these procedures. Check with your major carriers to obtain their policies on indications, pre-certification and/or waiver of liabilities that must be signed by the patient. The waiver alerts patients that their insurer may not allow reimbursement for these services. Here are the URLs to medical necessity policies for some major carriers:

Blue Cross Blue Shield of Massachusetts:  http://www.bcbsma.com/common/en_US/medical_policies/374.htm

HGSAdminitrators (CMS carrier/Pennsylvania):  http://www.hgsa.com/professionals/med-reports/mr0601.shtml  

Blue Cross Blue Shield of Tennessee: http://www.bcbst.com/MPManual/Autologous_Chondrocyte_Implantation.htm
 
ACI and open osteochondral allografts
 
Two open treatment CPT codes were added for reconstruction of articular cartilage defects: 27412, "Autologous chondrocyte implantation (ACI), knee," and 27415, "Osteochondral allograft, knee, open." According to the GSD, these procedures include: harvesting, application and sealing of covering graft; arthrotomy, knee; synovectomy and fat pad resection; diagnostic knee arthroscopy and arthroscopic chondroplasty, same compartment. The codes do not include meniscectomy and/or repair and meniscal transplant, according to the GSD. (Note that these are not osteochondral grafting codes [open or arthroscopic] for the ankle or other joints. An unlisted procedure code must be used in these situations.)   

The CPT Changes for 2005: An Insider's View states that: "Code 27412 was established to report performance of an open procedure of the knee for implantation of previously obtained autologous chondrocytes for treatment of diseased or injured articular cartilage. [ACI is] typically performed for lesions of the femoral condyle, the patellofemoral joint and medial or lateral articular cartilage lesions of the distal femoral condyles or trochlea. Since tissue graft (20926), knee arthrotomy (27331), exploration, removal of loose bodies, manipulation of the knee joint (27570) and fixation are included in chondrocyte implantation, codes 20926, 27331 and 27570 are NOT to be reported during the same session. Evaluation of cells for implantation prior to the procedure is also inherent and NOT reported separately.   

"Code 27415 was established to report open implantation of an osteochondral allograft in the knee performed for the treatment of moderate to large chondral or osteochondral defects."  

The CPT Manual 2005 also includes several cross references that pertain to bundling issues. It notes that codes 27512 and 27514 are not to be reported in conjunction with codes 20926, 27331, or 27570.    The code for harvesting chondrocytes for tissue culture (e.g. ACI) is 29870, "Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure).

Physician ICD-9-CM 2006, AMA copyright 2005 Ingenix  Current Procedural Terminology, copyright AMA 2005  Coding with Modifiers, A guide to Correct CPT and HCPCS Level II Modifier Usage, 2nd Ed. 2006