Changes in musculoskeletal section impact how code is applied
By Jeri Leong, RN, CPC
The American Medical Association released the 1999 CPT code book changes several months ago, and many will have a significant impact on the specialty of orthopaedics. Major revisions have taken place throughout the CPT book, including updated and revised codes, changes in coding guidelines, modifier revisions and additional symbols.
Additionally, numerous changes to the text itself, particularly in the musculoskeletal section, will impact how a CPT code should be properly applied.
A glance at Appendix B of the CPT 1999 Musculoskeletal Section (20000-29750) reveals the addition of two new CPT codes, 27347 (excision of meniscus or capsule lesion; knee) and 28289 (hallux rigidus correction).
Of exceptional significance, however, are the changes made to CPT codes that will alter their use dramatically. Many of these code revisions have created more specific code descriptors. For example, in CPT code 23000, the verbiage has changed from open method to any method. In code 27000, tenotomy, subcutaneous, closed is now percutaneous. The description for 27610 has deleted "for infection," so this code may now be used for other indications. Another revision is code 28092 that previously referred to toes, now refers to each toe. These examples are just a few of the many changes to CPT descriptor text that can significantly impact correct and optimal reporting of orthopaedic services. Coders and physicians should review all the 1999 changes and compare to 1998 codes to determine correct and compliant use.
OTHER CODE CHANGES
CPT modifiers have been moved from each subsection to appendix A. This move is intended to reduce confusion over which modifiers are appropriate for use with certain CPT codes. Of note is the deletion of modifier 20 (microsurgery). A new CPT code 69990 (use of operating microscope) is at the end of the surgery section and may be coded in addition to certain surgical CPT codes. Subsection guidelines instruct the coder not to report 69990 in addition to procedures where the use of the operating microscope is already a component (i.e., 20955. . ."microvascular"). Also of note, 69990 is considered to be an "add-on code" and should not be reported with modifier -51.
Another important change to the modifier section is the revision of modifier -25. The use of this modifier is still restricted to "a significant, separately identifiable Evaluation and Management Service by the same physician on the same day as a procedure or other service," but the CPT descriptor now states "the E/M service may be prompted by the symptom or condition for which the procedure was provided." In simpler terms, the orthopaedic patient may present with generalized knee pain, swelling and intermittent fever which is evaluated by the physician with, among other things, an examination, laboratory tests, or X-rays, then managed with the prescription of NSAIDS or antibiotic therapy. The physician may elect to do an arthrocentesis as part of this overall evaluation. As such, the visit could be reported with an E/M visit code (99201-99255) and modifier -25 and the procedure reported with the appropriate surgical code (20610), and separate diagnoses would not be necessary.
The medical record documentation, however, must clearly reflect evaluation and management of the medical problem (history, exam, and review of labs and X-rays, medical treatment) as being distinct from the procedure in order for both services to be considered for reimbursement. Additionally, modifier -62 (formerly known as co-surgery) has been clarified to note that two surgeons may work together performing distinct parts of a single procedure, rather than the previous description that required the surgeons have different skills to manage a procedure.
More visual aids have also been added to CPT 1999. The additions of two new symbols will greatly affect orthopaedic coding as both represent codes frequently used by this specialty. The first new symbol is the "+" which denotes "add-on codes." These are CPT codes that are commonly carried out in addition to a primary procedure and are sometimes called supplementary codes. These codes would never stand alone, as they always represent an additional service. An example is 26125, "fasciectomy, partial. . . each additional digit." When a CPT code is marked with a "+" it should be listed separately in addition to another code, and should never be used with modifier -51.
This is because these codes are not subject to the multiple surgery reduction rules as the relative value units have already been adjusted. A complete listing of these codes is contained in Appendix E.
The second new symbol is the O sign. This signifies CPT codes that are exempt from use with modifier -51. Similar to "add-on codes," these codes are exempt from the multiple surgery payment reduction rule. Careful post-payment review by the orthopaedic reimbursement specialist will be crucial to ensure payers are allowing proper consideration of these codes and not applying payment reductions inappropriately.
A complete listing of modifier -51 exempt codes can be
found in Appendix F.
Jeri Leong, RN, CPC, is a practice management consultant in Hawaii. She is the founder and past president of the Hawaii Chapter of the American Academy of Professional Coders (AAPC) and is a member of the AAPC National Advisory Board.
Answers to common coding questions may be addressed
in future editions of the Bulletin.