Could you be leaving money on the table without even knowing it? A quick way to find out is to test your knowledge of these five commonly missed or miscoded procedures. As you'll see, quite often the culprit is an op report that a physician didn't document well enough or a coder didn't read closely enough.
Claviculectomy performed with shoulder surgery.
The clavicle is joined at one end to the scapula or shoulder blade and at the other end to the sternum. The arthroscopic procedure for a partial distal claviculectomy (involving the removal of about 1cm of bone) is coded 29824. Code 23120 is for the open partial claviculectomy procedure and code 23125 is for the open total claviculectomy.
Keep in mind that a surgeon can perform an entire shoulder procedure arthroscopically. He may then perform a claviculectomy by a small incision, which you should code with the open code, rather than the arthroscopic code. Sometimes, the physician won't mention in the summary section of the op report that he performed a claviculectomy, making this a procedure that's easy to miss and code incorrectly.
Chondroplasty performed with knee arthroscopy.
Chondroplasty (or debridement) is frequently miscoded due to confusion over the Correct Coding Initiative, which unbundles edits for these codes. Rule No. 1: So long as you document that the chondroplasty procedure was performed in a separate compartment from the other procedure from which it is unbundled, you can bill for chondroplasty when you perform it with other arthroscopic knee procedures. This is so regardless of whether the 29877 code is unbundled in the CCI edits with an indicator of 0 or 1.
Billing Chondroplasty Procedures on Medicare Patients
The key is understanding which compartment the surgeon was in when he performed the chondroplasty and which compartment he was in (medial, lateral or patello-femoral, which includes the trochlear groove) when he performed the other knee arthroscopy procedure(s). Thorough review of these op reports is essential. Once you've clarified that the procedures were performed in different compartments, you're ready to code correctly for chondroplasty procedures. Keep these guidelines in mind:
- If the chondroplasty is performed in the same compartment with the other arthroscopic surgery procedures, it would be considered bundled in most cases, and would not be separately billable. Check the CCI unbundling material to be sure.
- The surgeon must document that he performed the chondroplasty in a different compartment than the repair or excision (in order to bill it with other procedures).
- Use the ?59 modifier on the 29877 chondroplasty code to indicate it was performed in a separate area.
- Chondroplasties can only be coded once per joint, regardless of how many compartments the surgeon debrides. So, for example, if the surgeon performs chondroplasty in more than one compartment, only use 29877 once.
Tendon grafts with ACL repair. When can you bill for obtaining a tendon graft used for arthroscopic ACL repairs? Only when you obtain it from the ankle area on the same leg or from the opposite knee. The 20924 code for a tendon graft states "from a distance." Billing 20924 code with the 29888 ACL repair code will likely be denied when you obtain the tendon graft from a separate incision on the same knee, because that's not considered to be a far enough distance to bill it separately, according to the CPT Assistant publication.
The physician's documentation in the op report must be extremely detailed to correctly code these procedures. Bill one code for each size/area of lesion that the surgeon removes. Bill the applicable code once for single or multiple tumors in the same size section. For example, if the surgeon fulgurates two small lesions, one medium tumor and three large tumors, you'd bill code 52234 x 1, code 52235 x 1 and code 52240 x 1. Don't add tumor sizes together to code these procedures; measure each tumor individually to determine the appropriate category from which to code. If the physician doesn't properly document tumor sizes in the op report, the pathology report won't be helpful, as the tumors are being fulgurated, not removed and sent for path.
Some other coding tips for bladder tumors:
- When lesions are fulgurated (using laser or cryosurgery) in the areas of the trigone, bladder neck, prostatic fossa, urethra or periurethral glands, use code 52214.
- For fulgurated bladder tumors classified as minor (less than 0.5cm), use code 52224.
- For fulgurated bladder tumors classified as small (0.5cm to 2cm), use code 52234.
- For fulgurated bladder tumors classified as medium (2cm to 5cm), use code 52235.
- For fulgurated bladder tumors classified as large (more than 5cm), use code 52240.
Use the 66982 code to bill difficult cataract procedures for those patients with special problems that make the procedure more difficult, require the surgeon to use unusual techniques and involve a higher risk. Patients in this category include pediatric patients (under age 8) and patients with weakened or absent lens support structures from glaucoma, small pupils, subluxated lens, pseudoexfoliation, trauma, Marfan syndrome or uveitis.
You can only use 66982 for conditions the physician identified before the surgery. You can't use the code for difficulty with a normal cataract procedure or obstacles that arise (unexpectedly) during the normal cataract surgical procedure. For diagnosis coding of this procedure, list the cataract code first, then use the diagnosis code (glaucoma, for example) for the problem that made the surgery fall into the difficult category as the second diagnosis code. You must support the medical necessity for billing of this procedure.
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- Stephanie Ellis, RN, CPC