December 2004 Bulletin

Stay abreast of changes for 2005

New CPT codes, updates to NCCI

By Margie Scalley Vaught, CPC, CPC-H, CCS-P, ACS-OR
and M. Bradford Henley, MD

With 2005 just around the corner, it’s time to take a look at the new CPT codes and their relative values under the Physician Fee Schedule. Several new codes have been added, particularly in the knee and spinal areas. Many of those codes were previously reported as unlisted or had Category III codes. The National Correct Coding Initiative (NCCI) Guidelines were also updated, effective Oct. 1, 2004. This column will address both areas.

New CPT codes in 2005

The CPT codes added in 2005 that relate directly to orthopaedic practice, along with their assigned Relative Value Units (RVU) and work expense values, are shown in the chart.

The new codes primarily concern spinal and knee procedures. However, the addition of DXA bone density studies is very encouraging, particularly in light of the Surgeon General’s report on osteoporosis and fragility fractures, released in October. (See related article)

Risk factor value

Another improvement in 2005 is the changing of the risk factor value for orthopaedic surgeons. This change finally recognizes the increased risk faced by orthopaedic surgeons, particularly relative to medical liablity insurance premiums. The risk factor value is now 8.06 for orthopaedic practices that perform nonsurgical/surgical without spinal procedures and 8.89 for practices that handle nonsurgical/surgical with spinal procedures.

This risk factor reflects the specialty-weighted approach to calculate the medical liability RVUs that was proposed in 1999 and takes effect in 2005. These risk factors are an index calculated by dividing the national average premium for each specialty by the national average premium for the specialty with the lowest average premium.

Updates to the NCCI guidelines

In October, CMS published several updates to the NCCI. Those of primary concern to orthopaedists include discussions of modifiers and modifier indicators, arthroscopic and open procedures, fracture reduction and general policy statements on knee arthroscopy and postoperative pain management.

“c. Modifier -58: Modifier -58 is described as a “staged or related procedure or service by the same physician during the postoperative period.” It indicates that a procedure was followed by another procedure or service during the postoperative period. This may be because it was planned prospectively, because it was more extensive than the original procedure or because it represents therapy after a diagnostic procedural service. When an endoscopic procedure is performed for diagnostic purposes at the time of a more comprehensive therapeutic procedure, and the endoscopic procedure does not represent a “scout” endoscopy, modifier -58 may be appropriately used to signify that the endoscopic procedure and the more comprehensive therapeutic procedure are staged or planned procedures. From the National Correct Coding Initiative perspective, this action would result in the allowance and reporting of both services as separate and distinct.

“d. Modifier -59: Modifier -59 has been established for use when several procedures are performed on different anatomical sites, or at different sessions (on the same day).

“Modifier –59 is often misused. The two codes in a code pair edit often by definition represent different procedures. The provider cannot use modifier –59 for such an edit based on the two codes being different procedures. However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, modifier –59 may be appended. Additionally, modifier –59 cannot be used with E & M services (CPT codes 99201-99499) or radiation treatment management (CPT code 77427). It is very important that NCCI-associated modifiers only be used when appropriate. In general these circumstances relate to separate patient encounters, separate anatomic sites or separate specimens. … Most edits involving paired organs or structures (e.g. eyes, ears, extremities, lungs, kidneys) have modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pair edits should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI edit indicates that the two codes cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations as recognized by coding conventions. However, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized.” (From General Correct Coding Policies, Chapter 1, E. Modifiers and Modifier Indicators)

Chapter 4 of the General Correct Coding Policies, focusing on the musculoskeletal system, includes the following information:

“Additionally, in accordance with the sequential procedure policy, when an arthroscopic procedure is followed by an open procedure at the same session, only the column 1 service is reported; generally, this would be the open procedure. If an arthroscopic service is performed at one site and an open procedure is performed at another, the arthroscopic service is reported with a modifier indicating that these services were performed at different anatomic sites (e.g. modifiers -RT or -LT, modifier -59, etc.).”

Fractures

The discussion of fractures in chapter 4 states:

“3. In accordance with the general policy on more extensive procedures, when a fracture requires closed reduction followed by open reduction at the same patient encounter (e.g. inability to accomplish the closed reduction), only the open reduction service is reported.”

Finally, chapter 4 includes the following general policy statements:

“8. CPT codes 29874 (Surgical knee arthroscopy for removal of loose body or foreign body) and 29877 (Surgical knee arthroscopy for debridement/shaving of articular cartilage) should not be reported with other knee arthroscopy codes (29871-29889). Report G0289 (Surgical knee arthroscopy for removal of loose body, foreign body, debridement/shaving of articular cartilage at the time of other surgical knee arthroscopy in a different compartment of the same knee).

“9. Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. CPT codes 36000, 36410, 37202, 62318-62319, 64415-64417, 64450, 64470, 64475 and 90780 describe services that may be utilized for postoperative pain management. The services described by these codes may be reported only if performed for purposes unrelated to the postoperative pain management.”

Each year brings new changes and updates, not only in CPT codes and NCCI guidelines, but in many Medicare national and local policies as well as in private carrier contracts. Orthopaedic offices need to stay abreast of the many additions, deletions, revisions and updates to guidelines and coding. With reimbursements getting tighter and tighter, it is especially important to ensure that all rules are followed to obtain the maximum allowable reimbursement.

Resources:

Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist in Ellensburg, Wash. A BONES member, she has served as a member of the National Advisory Board for the American Academy of Professional Coders. She can be reached at vaught@kvalley.com

M. Bradford Henley, MD, is a member of the AAOS CPT-ICD Coding Committee. He can be reached at henley@u.washington.edu

New CPT Codes in 2005

CPT Code/ Section

Description

Non-Facility/

Facility RVU

Work

Expense

27412
Knee/ Musculoskeletal

Autologous chondrocyte implantation, knee

42.36

23.23

27415
Knee/ Musculoskeletal

Osteochondral allograft, knee, open

35.37

18.49

29866
Knee/ Musculoskeletal

Arthroscopy, knee, surgical; osteochondral autograph(s) (eg, mosaicplasty) (includes harvesting of the autograft)

27.61

13.88

29867
Knee/ Musculoskeletal

Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

32.98

17.00

29868
Knee/ Musculoskeletal

Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

44.71

23.59

63050
Nerves/ Spinal Cord

Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments

37.23

20.75

63051
Nerves/ Spinal Cord

Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and nonsegmental fixation devices [eg, wire, suture, miniplates], when performed)

42.36

24.25

63295
Nerves/ Spinal Cord

Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) CPT Add-on Code

8.42

5.25

76077
Radiology

Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture assessment

1.04

 

97597
Medicine

Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters

1.29

 

97598
Medicine

Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters

1.64

 

97605
Medicine*

Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

   

97606
Medicine*

Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

   

0062T
Category III**

Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level

   

0063T
Category III**

Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels

   

*Classified as “bundled” codes with no additional RVUs assigned in the Nov. 15, 2004 Federal Register.

**Category III codes are not assigned RVUs


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