June 2003 Bulletin

Chondroplasty coding and documentation

Avoid confusion, review current changes

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Robert H. Haralson III, MD

Last year, the billing allowance for chondroplasty 29877 that was performed at the same time as other arthroscopic knee procedures was an on-again, off-again allowance by the Centers for Medicare and Medicare Services (CMS) and Correct Coding Initiative (CCI).

From January to March 31, 2002, CCI stated that 29877 was bundled into meniscectomy procedures and could not be billed even by using a modifier.

However, on April 1, 2002, CMS and CCI reversed their previous opinion [and allowances] and started to allow the billing of 29877 with modifier –59 when performed in a separate compartment from the meniscectomy.

This change in CCI 8.1 became retroactive to Jan 1, 2002. This allowed offices to resubmit claims that had been previously denied.

Then on October 1, 2002, CMS reversed their decision and bundled 29877 back into the meniscectomy, not allowing billing even with a modifier.

This left orthopaedic practices wondering when and how to bill.

During this time, the AAOS was trying to get the CCI and CMS to understand that there are three compartments to the knee that would meet the CCI description and policy of separate site and separate lesion for appropriate usage of modifier –59. CMS and CCI stated that they do not recognize the three compartments of the knee as separate anatomic sites.

Federal Register changes 2003 rules

However, in the December 31, 2002 Federal Register, the CMS unveiled a new Healthcare Common Procedure Coding System (HCPCS) code G0289. This code 55 represents, "Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee."

The Federal Register stated, "We are creating this code to permit appropriate reporting of arthroscopic procedures performed in different compartments of the same knee during the same operative session. This is an add-on code and should be added to the knee arthroscopy code for the major procedure being performed. This code is only to be reported once per extra compartment, even if both chondroplasty, loose body removal, and foreign body removal are performed. The code may be reported twice (or with a unit of two) if the physician performs these procedures in two compartments in addition to the compartment where the main procedure was performed. We examined the work RVUs, the intra-operative work intensity, and the intra-operative times for CPT codes 29874 and 29877. We also compared these intensities and times to those for CPT code 29870, the base procedure for this family. We determined a work value using the intra-operative intensity for CPT code 29874 (which is higher than for CPT code 29877) and the mean intra-operative times (for CPT codes 29874 and 29877) beyond the time required for CPT code 29870 (14 minutes for CPT code 29874 and 27 minutes for CPT code 29877). This code represents approximately 20 minutes of extra work at a high level of intensity. Therefore, the work value we are assigning to this code is 1.48 RVUs. We are assigning 0.27 malpractice RVUs to this procedure. This is the sum of the malpractice RVUs for CPT codes 29874 and 29877 beyond the malpractice RVUs for CPT code 29870, divided by two. We are not assigning any practice expense inputs to this code because it is an add-on code that will only be performed in the facility setting."

What this new code has done is take two CPT codes, 29877 and 29874, and lumped them into code G0289. Since the federal government referenced time in the Federal Register, this has opened up a whole can of worms as to documentation requirements.

To add further confusion on this code, outpatient hospital facilities were provided the information cited below from the CMS in Program Memo A-02-129, on how the coding should be done:

"This code should only be reported if the physician spends at least 15 minutes in the additional compartment performing the procedure. It should not be reported if the reason for performing the procedure is due to a problem caused by the arthroscopic procedure itself. This code is to be used when a procedure is performed in the lateral, medial, or patellar compartments in addition to the main procedure. However, CPT codes 29874, Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochrondritis dissecans fragmentation, chondral fragmentation) and 29877, Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) may not be billed with other arthroscopic procedures on the same knee."

This has some physicians receiving calls and/or letters from outpatient facilities asking that the surgeon document in the operative note that they spent in excess of 15 minutes on the chondroplasty.

In contacting the CMS office, the organization stated, "There is no specific place where the time needs to be documented, but we would assume that the time or work required would be documented in the operative note or some other similar place. We know orthopedic surgeons will frequently look in other compartments of the knee— scrape a little bit, etc. —for a couple of minutes–we don’t intend to pay that type of ‘look or see’ or minimal scraping separately."

AAOS efforts

AAOS has continued working to get CMS and CCI to overturn the bundling of 29877, prior to the implementation of the G code.

Here’s an excerpt of the letter to the AAOS Committee, from Niles R. Rosen, MD, medical director at the National Correct Coding Initiative, AdminaStar Federal, Inc., regarding some good news for previously denied chondroplasties:

"CMS will modify NCCI so that claims for 29880+29877 or 29881+29877 when performed in the different compartments of the knee can be paid if the date of service is prior to March 1, 2003. Since G0289 (arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee) will be effective March 1, 2003, NCCI will be modified to disallow 29877 when billed with 29880 or 29881 for a date of service on or after that date."

The necessary changes in NCCI will occur in NCCI version 9.2 scheduled for implementation on July 1, 2003. If a provider performed 29877 and either 29880 or 29881 in separate compartments on the same date of service prior to March 1, 2003, he/she has two options. The provider may defer submitting his claim to the carrier until after July 1, 2003, in which case the claim will not be impacted by the current NCCI edits. Alternatively, if a provider has a claim for a date of service prior to March 1, 2003 on which 29877 performed in a separate compartment was denied due to the NCCI edit with 29880 or 29881, the provider may submit the claim for adjustment to the local carrier after July 1, 2003.

For dates of service on or after March 1, 2003, the provider should bill G0289 rather than 29877 if a chondroplasty is performed in a separate compartment from the meniscectomy.

Bottom line

The chondroplasty issue continues to be a difficult and confusing coding and reimbursement issue. Orthopaedic surgeons need to document the full details involved in performing the chondroplasty, not just stating, "chondroplasty performed," in order to support billing.

As for Medicare patients, as of March 1, 2003, offices should be reporting G0289 that reimburses about $84 and is considered an ‘add-on’ code and thus falls under the global period for the other surgical procedures. For private payers, offices will have to continue to use CPT code 29877 if the carrier does not recognize the G code. If the carrier denies, offices will need to appeal and send in the supporting information from the AAOS Global Service Data and information from the Federal Register reference above or try to get the carrier to recognize the G0289.

Starting July 1, 2003, offices will want to start rebilling their previously denied claims with a date of service between October 1, 2002 and February 28, 2003 to all carriers to seek previously denied reimbursement.

Margie S. Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com

Robert H. Haralson III, MD, MBA, is the medical director of Southeastern Orthopaedics in Knoxville, Tenn. He is the chair of the AAOS CPT and ICD Coding Committee and the CPT advisor for the Academic Orthopaedic Society and has taught courses on the use of AMA Guides, CPT, the use of computers in medicine and disability medicine. He can be reached at (865) 769-4532 or at haralson@seortho.com.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.


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