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Orthopedic
Coder’s Pink Sheet
In ThIs Issue
Proposed ICD-9 2011 changes:
Look for new stenosis, nerve tumor and
blood type incompatibility codes .......................... 1
FAI:
UHC joins list of payers covering surgery
to treat condition ................................................ 2
‘Doc fix’ update:
21% Medicare cut now postponed until June ...... 3
CCI 16.1:
Look for new edits for fluoro,
artificial disk implant .......................................... 4
Health reform law:
Here’s a summary list of how it will
impact your practice ........................................... 6
Ask Margie:
Coding a hemi-to-total knee replacement ............ 7
Aspiration and injection in same joint .................. 8
Physician TipSheet:
List of proposed new, invalid and revised
ICD-9 codes for 2011 .................................. Insert
Ceu APProved
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Essential news and guidance to solve your
toughest speciality coding challenges
MAY 2010 | Vol. 11, Issue 5
Proposed ICd-9 2011 changes:
Look for new stenosis, nerve tumor codes
When coding for lumbar spinal stenosis, you could soon be
able to document the presence of neurogenic claudication, according
to new ICD-9-CM diagnosis codes proposed for implementation
on Oct. 1. Among the list of 141 proposed code changes are
a new code for lumbar spinal stenosis that includes neurogenic
claudication and one revised code without claudication.
Proposed ICD-9 changes were introduced in the proposed
hospital inpatient prospective payment systems (IPPS) rule, which
CMS released April 19. The final list of diagnosis code changes will
be released in July and take effect Oct. 1 this year.
The changes, which include 121 new, 11 invalidated and nine
revised codes, add new diagnoses covering a wide range of conditions,
including nerve tumors and retained fragments of foreign
bodies, as well as blood type incompatibility, multiple pregnancies,
cognitive deficits and extreme obesity (see full list of changes,
included as this month’s Physician TipSheet).
For the stenosis codes, the proposed changes include:
• revised code 724.02 (spinal stenosis, other than cervical,
lumbar region, without neurogenic claudication [includes
not otherwise specified]); and
• new code 724.03 (spinal stenosis, other than cervical,
lumbar region, with neurogenic claudication).
The change was requested by Andelle Teng, MD, a spine and
orthopedic surgeon in Auburn, Wash., who told the ICD-9-CM
Coordination and Maintenance Committee – which maintains
the code set – that a patient may have lumbar stenosis either with
or without neurogenic claudication. Lumbar stenosis is simply
defined as a narrowing of the lumbar spinal canal, which does
not imply a symptomatic or surgical condition (i.e., neurogenic
claudication), Teng states.
However, if stenosis at a single level becomes severe enough, or
if the nerves are being compressed by multiple levels of stenosis,
a patient may become symptomatic and experience neurogenic
claudication, which is a possible surgical condition, according to

May 2010 Orthopedic Coder’s Pink Sheet
Teng’s code request. Symptoms of neurogenic claudication
include buttock and lower extremity cramping, pain and
fatigue, exacerbated by standing erect.
Nerve tumors: You’ll have two new codes in the series
for neurofibromatosis (237.7), a genetic disorder that
causes tumors to grow along various types of nerves and,
in some cases, other tissue such as bone and muscle. In the
past, there have been two classified types of neurofibromatosis,
and ICD-9 codes already exist for these:
• Neurofibromatosis, type 1 (von Recklinghausen’s
disease) – 237.71 – is distinguished by spots and/or
nodules just beneath the skin, which can also lead
to enlargement and deformity of bone and scoliosis;
and
• Neurofibromatosis, type 2 (acoustic neurofibromatosis)
– 237.72 – can lead to multiple tumors on the
brain and/or cranial nerves, and often affects the
auditory nerve, causing hearing loss.
Now, a rare third type of neurofibromatosis has
emerged, called Schwannomatosis, and the ICD-9 Committee
has a proposed new code for it (273.73). The
additional code was requested by the American Academy
of Neurology. Patients with this disorder may have multiple
tumors on cranial, spinal and peripheral nerves, but they
don’t develop vestibular tumors or go deaf, as in Type 2 NF.
The ICD-9 Committee also proposed a new code
(273.78) for “other neurofibromatosis.”
Retained foreign body fragments: A series of proposed
new V-codes allow you to document when a patient
has retained fragments or splinters of substances that may
have become embedded in the body. The codes were
requested by the Department of Defense to identify materials
from bombs retained by injured soldiers; however, they
may be applicable to any injury resulting in embedded fragments.
They are to be used as secondary status codes to
primary injury codes, according to the ICD-9 Coordination
and Maintenance Committee. However, you should not use
these codes to describe implanted medical devices, such
as an artificial joint or pacemaker.
The list of proposed new codes for retained fragments
includes: depleted uranium (V90.01); other radioactive
fragments (V90.09); metal, unspecified (V90.10); magnetic
metal (V90.11); nonmagnetic metal (V90.12); plastic
(V90.2); animal quills or spines (V90.31); retained tooth
(V90.32); wood (V90.33); glass (V90.81); and stone or
crystalline fragments (V90.83), among others.
2
Any embedded object has the potential to cause infection,
the ICD-9 Committee notes. In addition, an embedded
magnetic object would be a relative contraindication for an
MRI exam. Other types of metal, such as lead or tungsten,
can also pose long-term toxicological risks.
In this update, the ICD-9 Committee proposes an additional
code (V15.53), for “personal history of retained
foreign body fully removed.”
Other proposed new diagnosis codes include:
• new V-codes for “personal history of (corrected)
congenital malformations” of various body systems,
including V13.68 (personal history of [corrected]
congenital malformations of integument, limbs and
musculoskeletal system);
• V49.86 (do not resuscitate status);
• three new code series that describe different
blood-type incompatibilities, including ABO incompatibility
(999.60-999.69), Rh incompatibility
(999.70-999.74) and non-ABO incompatibilities
(999.75-999.79);
• new V-codes for multiple pregnancies, including
twins to quads and “other specified multiple gestation,”
that allow you to code for the number of
placenta and amniotic sacs (V91.00-V91.99);
• V-codes that allow you to code body mass index
(BMI) for extremely overweight adults, from a BMI
of 40 to “70 and over” (V85.41-V85.45); and
• new cognitive deficit codes ( 799.50-799.59).
Official rEsOurcEs:
Hospital IPPS proposed rule:
www.federalregister.gov/OFRUpload/OFRData/2010-09163_PI.pdf
© 2010 DecisionHealth ® • www.ortho-decisions.com • 1-877-602-3835
`
`
ICD-9-CM Coordination & Maintenance Committee:
www.cdc.gov/nchs/icd/icd9cm_maintenance.htm
uhC is latest payer covering FAI surgery
An increasing number of private payers are electing to
cover either open or arthroscopic surgery to treat femoroacetabular
impingement (FAI), a painful hip condition
faced by some young, active patients.
Most significantly, UnitedHealthCare this spring announced
it will pay for both open and arthroscopic treatment
of FAI.

Orthopedic Coder’s Pink Sheet May 2010
“We are all dancing around at this office,” reports Kristi
Stumpf, MCS-P, CPC, COSC, ACS-OR, coding and compliance
supervisor, Proliance Orthopedics and Sports Medicine,
Bellevue, Wash.
“We do 10 to 12 of these cases weekly, sometimes more,”
she adds. That has led to a tremendous number of appeals
and an “unbelievable workload surrounding this procedure.
Finally, the tides are turning for us after years and
years of a complete and total nightmare!”
But while orthopedic coders celebrate the new UHC
policy, the battle is not over, Stumpf says. For example,
even if a big insurance company says it will cover FAI, the
patient’s individual plan (e.g., an employer-paid insurance
plan) may decide not to pay for it, Stumpf explains. “We’ve
had that happen in a couple of cases. You really have to dig
all the way down,” sometimes filing two separate pre-authorization
requests to nail down payment, she says.
That can also work to your benefit, however. For example,
even though Aetna formally has a non-coverage policy
for FAI, some of its private, employer-paid plans have opted
to cover it, she says.
The new UHC policy does not list specific indications
or conditions when FAI surgery would be covered. It states
only that “the best surgical outcomes are achieved in patients
who have ALL of the following:
• pain unresponsive to medical management
(e.g., restricted activity, nonsteroidal anti-inflammatory
drugs).
• moderate-to-severe persistent hip or groin pain that
limits activity and is worsened by flexion activities
(e.g., squatting or prolonged sitting).
• positive impingement sign (i.e., sudden pain on
90-degree hip flexion with adduction and internal
rotation or extension and external rotation).
• radiographic confirmation of FAI (e.g., pistol-grip
deformity, alpha angle greater than 50 degrees, coax
profunda and/or acetabular retroversion).
• do not have advanced osteoarthritis (i.e., Tönnis
grade 2 or 3) and/or severe cartilage damage (i.e.,
Outerbridge grade III or IV).”
Stumpf says the UHC FAI policy is similar to other
payers’ published policies for the procedure; they are all
vague. She states the condition itself may present differently
in different patients – the problem doesn’t always show up
on X-rays or MRIs, for example.
However most FAI patients fit a distinct pattern of not
being able to sit without pain because of bones abutting
against soft tissue, she says. From her experience, “what
payers really do want to see is that the patient did not
just walk in the door and you took them right to the OR,”
Stumpf explains. “They expect you to have attempted palliative
care at a bare minimum.”
UHC joins a growing list of commercial payers now
covering surgical intervention for FAI. CIGNA, Blue Cross
Blue Shield of North Carolina and Empire Blue Cross Blue
Shield (New York) have recently joined the list of payers
that say they will cover the procedure. Regence Blue Cross/
Blue Shield (Idaho, Oregon, Utah and some counties in
Washington) and First Choice of Washington were among
the first payers to cover FAI surgery (see OCPS, 9/09).
Medicare has no national coverage policy for FAI and
lists no local coverage policies for it. FAI is generally prevalent
among young, active patients, who don’t tend to be
Medicare beneficiaries.
Until CPT ® issues new codes for FAI surgeries (expected
as early as next year), most payers are directing you to
use 27299 for open treatment or 29999 for arthroscopic
FAI. There is no specific diagnosis code, so you’re likely left
with 718.85 (other joint derangement, NEC).
Official rEsOurcEs:
` Carrier FAI policies
` UHC: http://tinyurl.com/UHC-FAI-Policy
` CIGNA: http://tinyurl.com/CIGNA-FAI-Policy
` Empire BCBS: http://tinyurl.com/EmpireBCBS-FAI-Policy
` BCBS of North Carolina: http://tinyurl.com/BCBSofNC-FAI-Policy
` Regence BCBS: http://tinyurl.com/RegenceBCBS-FAI-Policy
President signs ‘doc Fix’ bill;
21% cut averted until June
President Obama signed, late on April 15, an unemployment
benefits extension bill (H.R. 4851), which contained a
measure postponing the sustainable growth rate (SGR) cut
to Medicare reimbursements until May 31. Lawmakers in
Washington must enact another pay-fix bill before June 1 to
again prevent the 21% cut to physician Medicare payments.
Claims with dates of service on or after April 1 had been
frozen by CMS to prevent practices from being paid at the
lower rate. However, that claims hold expired at midnight
on April 14. Medicare contractors had just begun process-
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May 2010 Orthopedic Coder’s Pink Sheet
ing these claims at the lower rate when the president
signed the extension bill, so the 21% cut was in effect for
less than 24 hours before Congressional action reversed it.
It is unclear how many claims were processed at the lower
rate, but CMS previously said these claims would be reprocessed
automatically in the event of a pay fix, without any
need for provider action.
The pay-fix bill previously would have extended the
fee fix until April 30, but this date was pushed back to May
31 in an amendment by Sen. Max Baucus, D-Mont. The
amendment delayed passage of the bill, which had to be
sent back to the House for a second vote. Fortunately, the
House moved quickly to give its approval.
CCI 16.1 tightens your coding
of fluoro, artificial disk implant
You’ll notice quite a few new code pairs bundling
fluoroscopy into injections in version 16.1 of the National
Correct Coding Initiative (CCI), which took effect April 1. In
addition, you’ll see that the artificial disk codes are bundled
into a number of other spinal fusion procedures, as is
Category III code 0195T (presacral arthrodesis).
On the nervous system side, look for new CCI code pairs
involving the codes for injection or destruction of the plantar
common digital nerve, e.g., Morton’s neuroma (64455
and 64632), among other edits.
Note also a new set of edits that will prevent you
from getting paid for newborn care per-day E/M codes
99460-99462 on the same day as a subsequent hospital
care service.
How CCI works: CCI is a form of claims processing
software used by your Medicare carrier – and some private
payers – to keep you from billing certain codes together
(e.g., components of a surgical procedure in addition to the
comprehensive procedure, or two codes that realistically
wouldn’t be performed together).
Correct Code Solutions LLC, Carmel, Ind., a CMS contractor,
maintains the CCI edits and updates them quarterly.
You can also review CCI’s policy manual (updated annually)
for many of the rules behind the edits. The full list of
CCI edits and the policy manual are available on the CMS
website (www.cms.gov).
CCI code pairs, or “edits,” affect codes you report for
the same patient, performed by the same provider on
4
the same day. Within a code pair, Medicare will pay the
“Column 1” (left-most) code. The code in “Column 2” gets
bundled, or denied.
A code pair with a modifier indicator of “1” means you
can use an appropriate modifier (e.g., 50, RT/LT, 78, 58,
59, 57 or 25) to override the edit. Modifier indicator “0”
means you can’t. Many of these edits may be overridden,
but be careful not to routinely override without documentation
of medical necessity. Keep in mind CCI edits represent
Medicare coding policy.
Unless otherwise noted, the CCI edits described
below all have a “1” modifier indicator, meaning the
appropriate modifier may be used to override the edits
when warranted.
Musculoskeletal
` Multiplane external fixation codes 20696 and
20697 have the following imaging codes as Column 2
components:
• 76942 (echo guidance for biopsy).
• 77002 (needle localization by X-ray).
• 77012 (CT scan for needle biopsy).
• 77021 (MR guidance for needle placement).
• 77031 (stereotactic guidance for breast biopsy).
` A number of new edits bundle cervical artificial disc
arthroplasty procedures as column 2 components of spinal
fusion to treat deformity and kyphectomy:
• Posterior fusion of 7-12 segments ( 22802) includes
cervical artificial disc arthroplasty (22856) and
removal (22864).
• Posterior fusion of 13 or more segments ( 22804)
includes 22856, 22861 (artificial disc revision)
and 22864.
• Anterior fusion, 2-3 segments ( 22808)
includes 22856.
• Anterior fusion, 4-7 segments ( 22810) includes
22856 and 22864.
• Anterior fusion, 8 or more segments ( 22812)
includes 22856, 22861 and 22864.
• Kyphectomy codes 22818 and 22819 include artificial
disc codes 22856, 22861 and 22864.
` Artificial disc codes also received their own new
Column 2 components:
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Orthopedic Coder’s Pink Sheet May 2010
•
•
•
Cervical artificial disc arthroplasty (22856) includes
components 22505 (manipulation of spine), 62291
(spinal diskography), 22220 (spinal osteotomy) and
22600 (cervical arthrodesis, single level).
Revision of cervical artificial disc (22861) includes
components 22220, 22505, 62291, cervical fusion
(22554 and 22600) and spinal fusion (22800, 22802,
22808 and 22810), as well as 22856.
Removal of cervical artificial disc (22864) includes
components 22220, 22505, 22554, 22600, 22800,
22808, 22845, instrumentation (22851), 22856, 62291,
and diskectomy (63075).
• Lumbar artificial disc arthroplasty ( 22857), revision
(22862) and removal (22865) all have 0195T (presacral
arthrodesis) as a Column 2 component.
` Injection for elbow arthrography (24220) includes
fluoroscopy codes 76000, 76001 as Column 2 components.
` Buttock fasciotomy (27027) includes hip/thigh fasciotomy
(27025) as a Column 2 component.
` Don’t forget: It is never appropriate for a surgeon to
report an anesthesia code for the surgery he is also performing.
Look for new edits bundling 01400 (anesthesia for
knee surgery) as a Column 2 component of all open knee
procedures, from incision and drainage (27301) to amputation
(27596). Similarly, anesthesia code 01404 is bundled
as a component of lower leg amputation (27598). Also,
anesthesia codes 01250, 01320 and 01400 are all Column
2 components of knee arthroscopy codes 29866-29889.
Note that these edits have a “0” modifier indicator.
` Category III pre-sacral arthrodesis code 0195T is a Column
2 component of lumbar spinal fusion (22630). In turn,
0195T has the following new Column 2 components:
• 22505 (manipulation of spine).
• 22830 (exploration of spinal fusion).
• 49000-49010 (abdominal endoscopy).
• 62290 (injection for spine disk X-ray).
Nervous system
` Percutaneous aspiration of intervertebral nucleus pulposus
(62267) has the following Column 2 components:
• 10021 (fine needle aspiration w/o image).
• 20220,
20240, 20245, 20250 and 20251
(bone biopsy).
• 77002 (fluoroscopic needle guidance).
` Fluoroscopic needle guidance code 77002 is a
Column 2 component of 62268 (aspiration of spinal cord
cyst) and 62269 (spinal cord needle biopsy).
` Percutaneous disk decompression (62287) includes
Category III code 0195T (presacral arthrodesis) as a
Column 2 component.
` Removal of implanted spinal infusion pump
(62365) is a Column 2 component of 62360 (reservoir
implant) and 62361-62362 (pump implant), all with a “0”
modifier indicator.
` Stereotactic spinal cord stimulation (63610)
includes fluoroscopy codes 77002 and 77003 as
Column 2 components.
` Fluoroscopy code 77003 is a Column 2 component of
nerve block codes 64510, 64520 and 64530.
` Fluoro codes 76000, 76001 and 77002 are Column
2 components of neurostimulator electrodes (64555) and
nerve destruction codes 64600, 64605, 64610 and 64620.
` Stimulator implant (64561) includes 76000, 76001,
77002 and 77003 as Column 2 components.
` Plantar common digit nerve destruction (64632)
is a Column 2 component of 64640 (destruction, other
peripheral nerve).
Orthopedic Conferences
Train your staff and keep your continuing education credits
up-to-date with these live conferences and webinars.
Bundling Intelligence: Achieving Maximum
reimbursement for orthopedic surgeries
speaker: Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P,
ACS-EM, ACS-OR
Wed., May 19, 1-2 p.m. ET
www.decisionhealth.com/conferences/A1967
2011 ICd-9 Codes: Learn how Key Changes Will Impact Your
documentation, Coding and Billing – and Your Bottom Line
speaker: Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P,
ACS-EM, ACS-OR
Thurs., May 20, 1-2:30 p.m. ET
www.decisionhealth.com/conferences/A1957
Advanced orthopedic Coding & reimbursement symposium
Loews Philadephia Hotel, Philadelphia
Sept. 12-15, 2010
www.decisionhealth.com/orthopedic_coding_reimbursement
For more information about all events, visit the websites
listed above or call 1-866-620-5939.
© 2010 DecisionHealth ® • www.ortho-decisions.com • 1-877-602-3835 5

May 2010 Orthopedic Coder’s Pink Sheet
` Injection into plantar common digital nerve, e.g.,
Morton’s neuroma (64455) includes the following Column
2 components:
• 29515 and 29590 (splint application).
6
• 29540 and 29550 (strapping).
• 29580 (application of paste boot).
• J2001 (injection, lidocaine hcl for intravenous
infusion, 10 mg).
Code 64455 is itself a Column 2 component of:
• 64640 (injection treatment of nerve).
• 64774, 64776, 64782, 64788 (nerve excision).
• 64795 (biopsy of nerve).
• 64820, 64831, 64834 (nerve repair).
• 64890, 64891, 64896, 64895 (nerve graft).
• 64905, 64907 (nerve pedicle transfer).
• 64910 (nerve repair w/allograft).
• 64911 (neurorraphy w/vein autograft).
Evaluation and management
` Subsequent hospital care codes 99231-99233 bundle
newborn care per-day E/M codes 99460-99462 as Column
2 components with a “0” modifier indicator.
` Newborn E/M code 99460 includes 99462 as a
Column 2 component. Also, code 99461 includes 99460
and 99462 as Column 2 components. All edits have a “0”
modifier indicator.
health reform law extends therapy
exemptions, shortens claims filing deadline
CMS is moving to implement provisions in the Patient
Protection and Affordable Care Act (PPACA), the official
name of the new health care reform law. Here is a brief
summary of actions the agency has taken so far, as well as
some of the other changes practices can expect.
Agency officials estimate that changes affecting physician
fees may take as long as 60 days to implement (even
if they retroactively take effect Jan. 1, 2010), because of
recalculations that will have to take place across all fee
schedules (e.g., hospital outpatient), according to officials
speaking on an April 13 conference call with providers.
Therapy cap exceptions process extended (Sec.
3103): Outpatient therapy service providers may continue
to submit claims with the KX modifier, when an exception
is appropriate, for services furnished on or after Jan.
1, 2010, through Dec. 31, 2010. For physical therapy and
speech language pathology services combined, and occupational
therapy services the limit on incurred expenses
is $1,860. Deductible and coinsurance amounts applied to
therapy services count toward the amount accrued before
a cap is reached.
New timely filing deadline for claims (Sec. 6404):
Providers no longer have 15 to 24 months to file Medicare
claims. PPACA now requires practices to submit claims
within 12 months of the date of service. That means a
claim for any service provided to a Medicare patient in
2010 will need to be submitted one calendar year later.
CMS says it will phase the new law in with the following
interim deadlines:
• Claims for services between Oct. 1, 2009, and Dec.
31, 2009, need to be submitted by Dec. 31, 2010.
• Claims for services rendered before Oct. 1, 2009, will
follow the previous rules for timely Medicare claims.
The change is considered a fraud, waste and abuse
provision, not just a change to make a provider’s life more
difficult. Also, the new timely claims rules are not set in
stone. HHS has the power to alter the timely claims provision
in future rulemaking.
Overpayments must be repaid sooner (Sec. 6402):
Effective immediately, providers have just 60 days to report
and return any overpayments they discover. Practices
could face civil money penalties if the government can
prove they should have known they needed to return
money to their carrier.
The work geographic index floor extended and the
practice expense geographic adjustment revised under
the Medicare physician fee schedule (Sec. 3102):
PPACA extends a floor of 1.00 on geographic price cost
index (GPCI) adjustments to the work portion of the fee
schedule through the end of 2010, with the effect of increasing
practitioner fees in rural areas. The law also provides
immediate relief to areas negatively impacted by the geographic
adjustment for practice expenses and requires the
HHS secretary to improve the methodology for calculating
practice expense adjustments beginning in 2012. Physicians
in more than 50 geographic localities will likely see a small
boost in their fees as a result of the GPCI adjustments.
CMS will continue to review misvalued codes
under the physician fee schedule (Sec. 3134): PPACA
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Orthopedic Coder’s Pink Sheet May 2010
directs the HHS secretary to regularly review Medicare
physician fee schedule rates, including services that have
experienced high growth rates. The law also strengthens
the secretary’s authority to adjust fees found to be misvalued
or inaccurate.
Payment for bone density tests (Sec. 3111): PPACA
restores payment for dual-energy x-ray absorptiometry
(DXA) services furnished during 2010 and 2011 to 70% of
the Medicare rate paid in 2006. The American College of
Radiology estimates this will increase the fee to about $98.
Presumed utilization rate increases for high-cost
imaging equipment (Sec. 3135): The presumed utilization
rate (PUR) helps Medicare set the technical payment
for imaging services in a non-hospital setting (e.g., physician’s
office). In effect, a higher UAR tends to drive down
the technical fee practices receive. PPACA will phase in a
gradually higher PUR for imaging services, starting at a rate
of 50% to 65% for 2010 through 2012, 70% in 2013 and 75%
thereafter. The law excludes low-tech imaging such as ultrasounds,
x-rays and EKGs from this adjustment. This provision
supercedes the CMS rule requiring the rate to increase
to 90% in 2013.
PQRI changes (Secs. 3002, 3003 and 3007): PPACA
extends the PQRI program through 2014 and allocates $75
million for quality measure development. You’ll continue
to receive bonus payments for quality reporting for another
four years, but bonuses will decrease over time from
current incentives of 2% of your overall Medicare charges
to 0.5% of charges in 2012, 2013 and 2014. Providers who
don’t participate in PQRI will see payments drop by 1.5%
in 2015 and 2% in 2016, according to the bill.
The bill also requires upgrades to PQRI feedback
forms by 2012 and public reporting of participation in the
PQRI program.
In 2015, CMS will start to phase-in a “value-based
payment modifier” to the physician fee schedule. The
modifier will adjust your payments based on the quality
and cost of care physicians deliver. You’ll start to see the
program develop in 2012 and physician fee schedule rulemaking
in 2013.
Limitation on Medicare exception to the prohibition
on certain physician referrals for hospitals (Sec.
6001): PPACA prohibits physician-owned hospitals that do
not have a provider agreement prior to Aug. 1, 2010, from
participation with Medicare. Such hospitals that have a
provider agreement prior to Aug. 1, 2010, could continue
to participate in Medicare under certain requirements addressing
conflict of interest, bona fide investments, patient
safety issues and expansion limitations.
A new independent payment advisory board
(Sec. 3403): The 15-member board will be formed to act
when Medicare costs are projected to be unsustainable,
but it may not ration patient care, raise taxes or change
premiums, eligibility or benefits. The board will look at
trends and can recommend that Congress implement new
payment models, such as pay-for-performance. Reports
from the board will no longer be non-binding, as MedPAC
reports are now. Congress must accept the board’s recommendations
or modify recommendations in a way that
doesn’t reduce their impact. The first of these reports is due
in 2014.
Contiguous body part discount rate to increase
(Sec. 3135): The discount CMS applies to imaging services,
such as X-rays, performed on contiguous body parts will
increase in 2011 to 50% from the current 25%.
Self-referral disclosure (Sec. 6003): PPACA adds an
additional requirement to the Medicare in-office ancillary
exception that requires the referring physician to inform
the patient in writing that the individual may obtain the
specified service from a person other than the referring
physician, a physician who is a member of the same group
practice as the referring physician or an individual who is
directly supervised by the physician or by another physician
in the group practice.
Official rEsOurcEs:
`
PPACA section-by-section summary:
http://dpc.senate.gov/healthreformbill/healthbill53.pdf
` Health reform law timeline: www.kff.org/healthreform/8060.cfm
Coding a hemi-to-total knee revision
Question: Patient underwent a medial unicompartmental
arthroplasty 19 years ago. He now presents with mechanical
symptoms and pain. X-rays demonstrate poly liner
completely dislodged and worn down to be bone on bone.
Surgery is performed to revise the medial unicompartmental
hemiarthroplasty to a total knee arthroplasty. As there is
not a “conversion of previous knee surgery to a total arthroplasty”
as there is for hips (27132), do we bill for removal of
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May 2010 Orthopedic Coder’s Pink Sheet
the previous prosthesis (27488) AND the total knee arthroplasty
(27447)? What is the most appropriate way to code
the procedures performed?
Answer: This question was posed recently to the AMA,
which checked with the American Academy of Orthopaedic
Surgeons, then responded that 27482-52 (revision of
total knee arthroplasty, with or without allograft, femoral
and entire tibial component) would be the most appropriate
code. You should append the 52 modifier (reduced
services) since the code describes revision of a total knee,
but you are revising only a unicompartmental arthroplasty.
It would not be appropriate to use 27488 (removal
of prosthesis, including total knee prosthesis, methylmethacrylate
with or without insertion of spacer, knee)
if you are putting another prosthesis in, according to
the AMA.
Aspiration and injection in same joint
Question: Can I report 20610 twice in the same joint –
once for aspiration and once for injection?
Answer: No, you can’t. I am starting to see this error
coming up in audits more and more for some reason. The
CPT descriptor for 20610 reads: “Arthrocentesis, aspiration
and/or injection; major joint or bursa (e.g., shoulder,
hip, knee joint, subacromial bursa).” The term “and/or”
in the description tells you the code “includes the performance
of one or all of the procedures described in the same
major joint or bursa,” CPT explains. “Therefore, code 20610
should only be reported one time when both aspiration and
injection are performed in the same major joint or bursa”
(CPT Assistant, March 2001).
Similarly, for knee or hip injections, at least, you also
may not report multiple units of 20610 for multiple injections
into the same joint.
A few years ago, I asked members of the American
Academy of Orthopaedic Surgeons’ (AAOS) Coding
Committee about separate reporting of injection codes
to the shoulder during the same treatment session (e.g.,
20610 to the glenohumeral joint and 20605 to the acromioclavicular
joint). In general, they agreed that separate
billing could be warranted if separate needles were
used. In the shoulder, the AC and GH joints are separated
by the joint capsule. By contrast, in the knee, once the
solution is injected it will cover the medial, lateral and
patellofemoral compartments.
8
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Orthopedic Coder’s Pink Sheet May 2010
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