AAOS Bulletin - June, 2005

Introducing five new knee codes

Additions cover transplants, grafting

By Margie Scalley Vaught, CPC, CPC-H, CCS-P, ASC-OR; M. Bradford Henley, MD; William Beach, MD; and Mel Friedman, MD

As mentioned in the April Bulletin, five new knee procedure codes were added to the Current Procedural Terminology (CPT) in 2005. This column will cover the new procedure codes as well as coding for minimally invasive joint replacement procedures.

Meniscal transplant

The new code for arthroscopic meniscal transplantation is 29868. According to the AAOS Global Service Data Book (GSD), this code includes the following procedures: diagnostic arthroscopy; lavage and/or drainage; lysis of adhesions; and minor synovectomy for visualization.

The GSD also states that removal of loose bodies, arthroscopic chondroplasty (in a different compartment) and arthroscopic abrasionplasty can be separately reported as they are considered excluded. In general, the AAOS editorial panel for the GSD considers removal of loose bodies to be a separately reportable service when the loose bodies are of sufficient size that they require removal through a separate incision or when they are too large (e.g. >5mm) to flow out through an arthroscopic sheath. Because most payors require that medical necessity be established preoperatively, the specific diagnosis of “loose body(ies)” should be made prior to preauthorization.

However, the CPT Changes for 2005: An Insider’s View says that code 29868 includes all of the following actions: preparation of the defective area; removal of the damaged portion of meniscus; creation of tibial tunnels or a bone trough as stabilizing structures for the implant; insertion of the meniscal graft via arthrotomy; joint exploration; synovial biopsy; lavage, drainage and removal of loose bodies; synovectomy; meniscectomy; medial and lateral meniscus repair; and lysis of adhesions.

Before the CPT Changes for 2005 was printed, the intention was that code 29868 would include 29881 (meniscectomy), 29877 (chondroplasty) and 29874 (loose body removal) when performed in the same compartment as the meniscal transplant, but not when they were performed in the other compartments. However, as the result of a typographical error, the printed edition states that 29881, 29874 and 29877 cannot be listed and reimbursed with code 29868.

The AAOS Coding, Coverage and Reimbursement Committee applied for and has been granted a change in 2006, thereby correcting this error. A parenthetical note in the 2006 manual will confirm that separate compartment coding is permitted.

The CPT Coding Manual 2005 also includes several cross references that address bundling issues. Under the guidelines, procedures such as diagnostic scope (29870), lavage (29871), synovectomy (29875), removal of loose body(ies)(29874), meniscectomy (29880 and 29881), meniscus repairs (29882 and 29883) and lysis of adhesions (29884) are NOT to be reported separately when these procedures are performed at the same session and in the same compartments.

Arthroscopic mosaicplasty (knee)

Two new arthroscopic codes were added for osteochondral grafting—one for an autograft and the other for an allograft. Code 29866 covers “Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft).” Code 29867 covers “Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty).”

According to the AAOS GSD, use of codes 29866 or 29867 would include diagnostic arthroscopy, lavage and/or drainage, lysis of adhesions and minor synovectomy for visualization. However, removal of loose bodies, arthroscopic chondroplasty of a different compartment and arthroscopic abrasioplasty are excluded under these codes.

The CPT’s view on bundling for osteochondral grafting is covered in CPT Changes for 2005: An Insider’s View, which states:

“Code 29866 was established to report scope osteochondral autograft harvest and implantation of femoral peripheral cartilage in the knee. As this procedure typically requires the placement of multiple grafts, code 29866 is reported one time per procedure, regardless of the number of grafts obtained and inserted. Harvest of the autograft is NOT reported separately in addition to 29866, as acquisition of the graft is inherent in the scope of osteochondral autograft implantation.

“Code 29867 was established to report the performance of scope repair of lesions of the femoral condyle with placement of osteochondral allograft arthroscopic. An instructional note following 29867 also indicates that open code 27415 is NOT appropriately reported in addition to the scope procedure at the same session.”

The CPT Coding Manual 2005 includes several cross references on bundling issues. Based on this manual, the following procedures would be considered bundled when performed in the same compartment with code 29866: diagnostic scope (29870), lavage (29871), synovectomy (29875), removal of loose body(ies)(29874), chondroplasty (29877), abrasion chondroplasty (29879), drilling of osteochondritis dissecans (29885-29887) and lysis of adhesions (29884).

Originally, 29877 and 29874 were to be included when performed in the same compartment but not if performed in a different compartment. A typographical error stated 29874 and 29877 couldn’t be listed and reimbursed. The AAOS Coding, Coverage and Reimbursement Committee applied for and has been granted a change in 2006, to correct this error. The AMA will note that separate compartment coding can be performed in the 2006 manual.

Many insurance companies have carrier-specific polices covering these procedures. Check with your major carriers to obtain their policies on indications, pre-certification and/or waiver of liabilities that must be signed by the patient. The waiver alerts patients that their insurer may not allow reimbursement for these services. Here are the URLs to medical necessity policies for some major carriers:

• Blue Cross Blue Shield of Massachusetts: http://www.bcbsma.com/common/en_US/medical_policies/374.htm

• HGSAdminitrators (CMS carrier/Pennsylvania): http://www.hgsa.com/professionals/med-reports/mr0601.shtml

• UniCare Life and Health Insurance Company: http://medpolicy.unicare.com/policies/TRANS/chondral_defect_trans.html

• Blue Cross Blue Shield of Tennessee: http://www.bcbst.com/MPManual/Autologous_Chondrocyte_Implantation.htm

• Washington State Department of Labor and Industries: http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/SpecCovDec/default.asp

ACI and open osteochondral allografts

Two open treatment CPT codes were added for reconstruction of articular cartilage defects: 27412, “Autologous chondrocyte implantation (ACI), knee,” and 27415, “Osteochondral allograft, knee, open.” According to the GSD, these procedures include: harvesting, application and sealing of covering graft; arthrotomy, knee; synovectomy and fat pad resection; diagnostic knee arthroscopy and arthroscopic chondroplasty, same compartment. The codes do not include meniscectomy and/or repair and meniscal transplant, according to the GSD. (Note that these are not osteochondral grafting codes [open or arthroscopic] for the ankle or other joints. An unlisted procedure code must be used in these situations.)

The CPT Changes for 2005: An Insider’s View states that: “Code 27412 was established to report performance of an open procedure of the knee for implantation of previously obtained autologous chondrocytes for treatment of diseased or injured articular cartilage. [ACI is] typically performed for lesions of the femoral condyle, the patellofemoral joint and medial or lateral articular cartilage lesions of the distal femoral condyles or trochlea. Since tissue graft (20926), knee arthrotomy (27331), exploration, removal of loose bodies, manipulation of the knee joint (27570) and fixation are included in chondrocyte implantation, codes 20926, 27331 and 27570 are NOT to be reported during the same session. Evaluation of cells for implantation prior to the procedure is also inherent and NOT reported separately.

“Code 27415 was established to report open implantation of an osteochondral allograft in the knee performed for the treatment of moderate to large chondral or osteochondral defects.”

The CPT Manual 2005 also includes several cross references that pertain to bundling issues. It notes that codes 27512 and 27514 are not to be reported in conjunction with codes 20926, 27331, or 27570.

The code for harvesting chondrocytes for tissue culture (e.g. ACI) is 29870, “Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure).”

MIS joint replacement

Several carriers have weighed in on the coding of a total joint arthroplasty (TJA) when minimally invasive surgery (MIS) techniques are used. Modifier -22 should not be used in reporting MIS TJA procedures. The codes for joint replacement procedures always include the surgical approach, whether it is done through a single incision, or two or more incisions. The established joint replacement codes have no relationship to the length of the incision(s) used to perform the reconstruction. Most carriers are not allowing additional reimbursement for MIS surgery and are not recognizing the modifier -22 when used for MIS surgery.

Technically, the TJA procedure being performed is already represented by a CPT code. Making smaller incisions to perform the TJA does not meet the requirements of “unusual.” Carriers have implied that MIS total knee replacement is similar to the mini-open rotator cuff repair, which is another procedure that requires the use of an “open” (i.e. not arthroscopic) code.

M. Bradford Henley, MD, is professor of orthopaedic surgery at the University of Washington and chairman of the AAOS Coding, Coverage and Reimbursement Committee. He can be reached at bhenley@u.washington.edu. William R. Beach, MD, and Melvin M. Friedman, MD, are members of the the committee.

Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist in Ellensburg, Wash. She can be reached at vaught@kvalley.com

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