Frequently asked coding questions
Members frequently request coding assistance from the AAOS. Following are answers to common questions prepared by coding specialist Margie Vaught.
We have a question regarding why codes 11012 and 26951 are considered bundled according to the "Correct Coding Initiative." Can you give us information regarding this issue? We also have the same question regarding codes 25810 and 25215.
In answer to the first question regarding 11012 and 26951, according to the Global Service Data for Orthopaedic Surgeons these two procedures can be billed together and are not considered "inherent" to each other. There must be good documentation supporting the excessive debridement that the surgeon is asking for with code 11012. Please remember that with procedure 26951 there is some debridement and irrigation that is "inherent" in the procedure. It is up to the physician to document that the amount of debridement was in excess of the normal amputation. If you are being denied routinely for this from payers, you may want to send a letter with a copy of the information from the AAOS book "Global Service Data." As you are well aware, the CCI edits change daily, however there are no updates given except quarterly. This particular bundling pair, per CCI 7.3, allows for the billing of 26951 and 11012 as along as modifier is appended, such as 59 to show that the debridement was separate and distinct and went above and beyond the debrided included in code 26951.
What is the "rule of thumb" for the following situation:
Doctor #1 performs an Admission History & Physical and a surgical procedure on 2/2/01.
Doctor #2 (from same practice) wants to charge for a Hospital Visit on the same patient on 2/3/01, which is the same date of discharge.
Can Doctor #2 charge for the hospital visits or is that considered under the global concept?
Since Dr 1 and Dr 2 are in the same group practice (same tax identification number), Dr 2 can not charge for a hospital visit postoperatively unless it is for an unrelated diagnoses. You did not state if Dr 1 and Dr 2 are in the same specialty or if Dr 2 was seeing the patient for an unrelated diagnosis. If Dr 2 is just covering for Dr 1 and discharging the patient for him, he can not charge for this during the global period. Rule of thumb is that patients being seen in a group practice (same specialty) during a global period should not be charged for routine follow-up related to the operative procedure (same diagnoses). The only time that you can charge a patient during the global period is for complications and/or unrelated diagnoses. This information can be found in the AAOS Global Service Data book in addition to the Medicare Carriers Manual and the CPT manual under "Global Service".
Im having a difficult time in finding information about 20900 & 20902. The physician states that he takes bone from the iliac to graft into the radius, nothing more and wants to bill for 20902. What determines the appropriate code to use? 20900 states "Minor, small, like a button or dowel" and 20902 states "Major, large, larger than a button or dowel". By reading what limited information that I can obtain, it leads me to think that the size of the graft has to be stated. The physician replies to me that he thinks, (20900) "I think these refer to grafts taken percutaneously with a trephine (hollow cylinder with teeth). (20902) Therefore open taking of graft should be major!" Can you help or advise me to where I could find the answer?
First both code 20900 and 20902 require an incision to be made. This can be located in CPT Assistant Dec. 2000, Musculoskeletal System Question & Answer.
Usually what is meant by minor or small (20900) is the place selected (anatomy site) for the bone graft such as the radius for scaphoid fracture grafting; major or large (20902) is usually what is used for iliac crest or larger anatomy structures.
Also if you note in the AAOS Global Service Data it shows that code 20900 is inherent in 20902.