Inform insurance carriers about a procedure, code you'll use until a new code is approved
By Margie Scalley Vaught
We all have been told that if unlisted procedures are used, the billing will become "lost in space," so to speak. However, with so many procedures being done using different methods, it is difficult to know exactly what CPT code should be used.
The rule of thumb once was that if the procedure being performed was listed as an open procedure in the CPT book, and that only the approach was different, it should be coded as if it were an open procedure; i.e., carpal tunnel release (64721). That was before there was the endoscopic code for this procedure. However, now the American Medical Association has stated that unlisted codes must be used, even if the approach is the only thing that is different in the published CPT code. Their rationale for this is one of quality and documentation.
If there is a need for a new code to be added to the CPT manual, the AMA wants to hear about it. How many of you have noticed that in the front of the CPT manual there is a form that can be sent in to the AMA to petition for new codes?
This may produce new codes in the future, but what about getting reimbursed for services performed now? How does one get insurance companies to understand what the procedure is so that payment can be made? While waiting for the AMA to come up with new procedure codes or revised codes, here are some pointers to get paid for those "unlisted procedures."
Contact your various insurance carriers via letters, letting them know that you are doing a procedure with a different approach. One example is arthroscopic Bankhart procedures. This is only listed as an open procedure 23455. In your letter to the carriers, let them know that what is being done is similar to the 23455, however, it is being performed arthroscopically. Let them know that until there is a new CPT code for this procedure, you would like to bill these procedure with the 23455, adding the appropriate modifier -52 or -22, depending on whether the surgeon believes that the work involved is less or greater than the open procedure.
In order to determine this, you must take into account the decrease in the size of the surgical incision and dissection and also the time required for closure. These components are valued at about 20 percent of the procedure. If the surgeon believes that he/she makes up that 20 percent in the difficulty of the arthroscopic technique, then the surgeon needs to explain that and does not add a modifier. If, however, the surgeon believes that even with the difficulty of the arthroscopic technique, it still does not make up for the 20 percent previously allowed for the open approach, a -52 modifier would be allowed and fees adjusted accordingly. If the surgeon believes that this technique is more difficult, then modifier -22 should be appended.
Present this information to the insurance carriers and ask them to respond in writing whether or not this is acceptable during the period of waiting for the appropriate CPT codes to be established. You will be surprised at how many insurance carriers will be grateful for your explanation of the situation, because they also do not like auditing unlisted procedures.
This same method of establishing reimbursements can be used for
procedures that include part of a listed CPT code, but the surgeon
did not perform all the components of that procedure. Insurance
carriers like to be able to compare the procedures to those already
listed in their fee schedules and those that have been assigned
What is the coding for concurrent bilateral total knee replacements
being done by two different surgeons and two different assistances?
Surgeon A would code for the right total knee arthroplasty (27447-RT) and Assistant 1 would code also for the assistance on the right TKA (27447-80-RT). Surgeon B would code for the left total knee arthroplasty (27447-LT) and Assistant 2 would code for assisting on the left TKA (27447-80-LT). Each surgeon will need to do their own operative note stating the procedure was performed by them and who assisted.
However, one thing needs to be clear. In your scenario the surgeons are not assisting each other because you stated that they each had their own assistant. If the surgeons are assisting each other on these total knee arthroplasties (co-surgeons), this coding would not be appropriate.
Regarding follow-up care, each surgeon should be following up
on the total knee they performed. It will be important to indicate
the appropriate side (RT or LT) that they are responsible for
on all records and codes, i.e., 73560-RT. There should
not be a problem regarding follow-up, because this is an inherent
portion of the global charge of 27447.
Margie Scalley Vaught, CPC, is an independent coding specialist
in Ellensburg, Wash. She also is a member of the American Academy
of Professional Coders National Advisory Board.
Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.