Fine Details Are Critical in Fracture Coding

By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P

Analyze documentation to understand the intricacies of diagnostic and procedural fracture coding.

Because there are so many types of fractures and fracture treatments, appropriate diagnostic and procedural coding is very complex. Obtaining appropriate reimbursement in compliance with payer regulations and coding guidelines requires a thorough analysis of the documentation. Before you can do that, however, you have to understand what you’re looking at, and know which details you’re looking for.

Code by Location/Open or Closed

The formal definition of fracture in ICD-9-CM is, “a complete or incomplete break in a bone resulting from application of excessive force.” The ICD-9-CM Alphabetic Index (Volume 2) arranges fracture diagnosis codes alphabetically by location, and often by relative position of a given site (e.g., distal end or proximal end). For example, the entry “fracture; clavicle” contains codes specific to the interligamentous region, the acromial end, the shaft (middle third), and the sternal end of the bone.

The first three digits of a fracture diagnosis code identify the general location of the fracture (e.g., 800.xx-804.xx for skull fractures, 805.xx-809.xx for neck and trunk fractures, etc.). The fourth digit generally identifies the fracture as either open or closed. Open means there is a skin wound caused by the fracture. Closed means there is a breakage of bone but not of surrounding skin. If a fracture is not specified as either open or closed, you must assume it is closed, as indicated by an instructional note at the beginning of ICD-9-CM chapter 17, in the Fractures section (categories 800-829).

Most ICD-9-CM fracture diagnoses require a fifth digit. Typically, the fifth digit of a fracture repair diagnosis code indicates more specific bones within the general site, but may also indicate other specified information. For example, when coding for skull fracture (800.xx-804.xx), the fifth digit indicates if there was a loss of consciousness, how long it lasted, and whether there was a return to the previous level of consciousness. Clinicians should be careful to document these and other associated conditions (e.g., spinal cord injury).

Stress Fractures May Warrant Causation Codes

Clinicians and coders must often distinguish between traumatic fractures (caused by an acute injury), pathologic fractures (caused by an evolving disease process that weakens bone, such as osteoporosis), and stress fractures (due to repeated strain from overuse).

Traumatic fractures are reported from ICD-9-CM categories 800-829 while the patient is receiving active treatment, such as surgical or emergency department care. Aftercare treatment requires different codes (see “Fracture Aftercare Calls for Unique Coding” on page 42 for more detail).

To identify a pathologic fracture receiving active treatment, report 733.1x.

For example, a 58-year-old man is diagnosed with a pathologic fracture of his C6 spinous process. Because this is a pathologic fracture, the correct code is 733.13 Pathologic fracture of vertebrae.

If the same patient had suffered from a traumatic fracture, you would code from category 800-829. For the C6 spinous process, you would report 805.06 Fracture of vertebral column without mention of spinal cord injury; cervical, closed; sixth cervical vertebra.

A stress fracture, aka an insufficiency fracture, is caused by repeated strain from overexertion or due to a weakened bone (i.e., osteoporosis). Look to category 733.93-733.99 to report stress fractures. Also assign the appropriate diagnosis code to describe any underlying external cause.

For example: A 13-year-old boy was lifting heavy weights at his school’s gym when he began to clutch his left knee in pain. He was diagnosed with a stress fracture of his tibia shaft. Because this is a stress fracture rather than an impact fracture, and is specified as of the tibia, the proper code is 733.93 Stress fracture of the tibia or fibula. You must also specify the external cause of the stress fracture, including E927.0 Overexertion from sudden strenuous movement and E010.2 Activity involving other muscle strengthening exercises; free weights. You can also specify place of occurrence, E849.6 Place of occurrence; public building.

History of pathologic fracture or stress fracture, when documented, should be reported secondarily to the active fracture. The history codes are V13.51 Personal history of pathologic fracture and V13.52 Personal history of stress fracture.

Tips for Diagnosis Sequencing

ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.17.b) stipulates three primary rules for assigning and sequencing fracture diagnoses:

1. Code all fractures separately. This includes multiple unilateral or bilateral fractures classified to different fourth-digit subdivisions (bone part) within the same three-digit category (bone).
2. Combination codes are used only for triage on patients with multiple injuries when the extent of the individual injuries is unknown prior to transfer of care.
3. Report multiple fractures by severity (most severe first), as determined by the treating physician.

For example, following a motor vehicle accident, the patient arrives in the emergency department with multiple open depressed skull and facial bone fractures, facial lacerations, and contusions. She has experienced a 90-minute loss of consciousness. The appropriate ICD-9-CM code is 804.63 Multiple fractures involving skull or face with other bones; open with cerebral laceration and contusion; with moderate [1-24 hours] loss of consciousness. In this case, a combination code may be used. The code also describes other, associated conditions (e.g., loss of consciousness).

CPT^® Coding for Fracture Treatment

“Fracture” appears in the CPT® Index as a main term (just as it does in ICD-9-CM). This is where you’ll begin your search for fracture treatment codes. The terms “fracture” and/or “dislocation” appear at the category level in the main section of the CPT® codebook. For example, codes 27750-27848 represent treatments of fractures of the tibia, fibula, and ankle joints.

There are three major approaches to treat fractures: closed, open, and percutaneous.

• Closed treatment means the fractured bone is not exposed to the view of the surgeon.
• Open treatment means the bone is exposed by incision.
• Percutaneous treatment (aka percutaneous skeletal fixation) involves the placement of a fixative device—such as a rod, wire, or pin—across the fractured bone usually under imaging guidance.

The treatment type will not necessarily match the fracture type. For instance, an orthopedic surgeon may perform an open treatment of a closed fracture, or a percutaneous treatment of either a closed or open fracture.

When coding for physician services for surgeries to correct fractures, pay particular attention to terms such as closed/open/percutaneous treatment and details describing the specific site (such as nasal bone, nasal septum, nasoethmoid, nasoethmoid complex, or nasomaxillary). You’ll also need to understand which combinations of terms are mutually exclusive with each of the three treatment methods. Read all CPT® descriptors carefully, noting terms such as “open reduction with internal fixation.” Observe when certain services (such as the application of the fixative device) are included in the descriptor, and not reported separately.

For both procedural and diagnostic coding, experts generally agree that if one bone is both fractured and dislocated, code only the service and diagnosis for the fracture and not the dislocation (see Coding Clinic, third quarter 1990, page 13). Some CPT® codes specifically describe surgeries on a bone that is both fractured and dislocated.

For example, an 87-year-old man with history of falling presents for repair of fractured proximal ulna and dislocated radial head. He slipped on ice, landing on his right elbow, and sustained a Monteggia fracture. The orthopedic surgeon performed an open reduction and internal fixation (ORIF) over the site.

The correct CPT® and ICD-9-CM codes to describe this scenario are:

• 24635-RT Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed-Right side to describe the ORIF for Monteggia fracture.
• 813.03 Fracture of radius and ulna; upper end, closed; Monteggia’s fracture for the traumatic fracture. Because the fracture is not indicated as open, you would code it as closed.
• V15.88 History of fall indicates the patient has a history of falling.
• E885.9 Fall from other slipping, tripping, or stumbling describes a fall on same level, such as slipping.
• E849.0 Place of occurrence, home notes where the fracture occurred.

You would not code the dislocation because the same bone is also fractured.

In a second example, a 26-year-old woman is injured in a downhill skiing accident. She fractures and dislocates her left shoulder. The impact was to her left distal humerus, medial condyle. Using anesthesia, the orthopedic surgeon repairs her shoulder by reducing the fracture without directly visualizing the injured site.

The correct CPT® and ICD-9-CM codes are:

• 23665-LT Closed treatment of shoulder dislocation with fracture of greater humeral tuberosity, with manipulation; requiring anesthesia-Left side. Because the orthopedist performed the surgery without visualizing the fracture site, this is a closed treatment.
• 812.43 Fracture of humerus; lower end, closed; medial condyle. Do not code the dislocation as well because the fracture of the same bone is the more serious injury.
• E885.3 Fall from skis
• E003.2 Activities involving ice and snow; snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing and snow tubing

This is a lot of information to take in. In a nutshell, just remember: Diagnosis coding should report the location of the fracture, the severity of the fracture, and whether there were complications due to the fracture. Procedure coding should report the approach for treatment, the location being treated, and any extenuating circumstances due to treatment.

 Sidebar

Fracture Aftercare Calls for Unique Coding

Codes 800-829 for traumatic fractures, 733.1x for pathologic fractures, and 733.93-733.99 for stress fractures should be reserved for when the patient is receiving active treatment for the fracture. ICD-9-CM Official Guidelines for Coding and Reporting defines active treatment as “surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”

When reporting services provided during the healing or recovery phase of the fracture, turn instead to fracture aftercare codes from category V54. Examples of aftercare include cast change or removal, removal of external or internal fixation devices, medication adjustment, and follow-up fracture treatment visits.

Sidebar

ICD-10-CM Ups the Documentation Ante

As ICD-9-CM gives way to ICD-10-CM on Oct. 1, 2014, the importance of complete documentation for fracture coding will take a big leap forward. To cite two examples: In ICD-9-CM, there is no provision for specifying laterality (left or right) and healing processes are very broadly classified. For example, there is only one code for a malunion of a fracture (733.81) and only one code for a nonunion (733.82).

In ICD-10-CM, not only do we indicate laterality but we also have the capability to code a disease process known as “stage of healing.” The four distinct fracture healing processes are:

• Routine healing
• Delayed healing
• Nonunion
• Malunion

These features, as well as routine and delayed healing, are built into the seventh-character “extension” of the ICD-10-CM code. Aftercare following fracture treatment is indicated by the extension “D,” and late effects of fractures are indicated by the extension “S.” In ICD-10-CM, closed and open fractures are further broken down into many subdivisions, which are only tabulated in a list in ICD-9-CM.

When mapping fracture codes from ICD-9-CM to ICD-10, it becomes clear that much more information must be documented in medical records and operative reports. For example, a patient suffers a traumatic open fracture to the lower end of the femoral condyle. In ICD-9-CM, this is simply coded as 821.31 Fracture of other and unspecified parts of femur; lower end, open; condyle, femoral. In ICD-10-CM, however, we add the dimensions of:

• Which condyle (unspecified, lateral or medial; fifth character)
• Laterality (right or left thigh or unspecified; sixth character)
• Whether displaced or nondisplaced (also in the sixth character)
• Type of open fracture (using the Gustilo Open Fracture Classification System; seventh character extension)
• Stage of healing (as listed above; also in the seventh character)

A single ICD-9-CM code (821.31) potentially crosswalks to 36 possible ICD-10-CM code choices in the category S72.4- (including three designations of condyle, three designations of laterality, two binary designations of displacement, and two designations of Gustilo groups [Type I/II and Type IIIA/IIIB/IIIC]). The S72.42- and S72.43- subseries follow a similar progression, with the fifth character representing the lateral condyle in S72.42- and the medial condyle in S72.43-. All of these codes map backward from the general equivalence mapping (GEM) files to 821.31.

March 1st, 2013

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J1 MAC: Percutaneous Endovascular Cardiac Assist Covered

It isn’t every day a Medicare administrative contractor (MAC) says it will cover a procedure that has neither a specific CPT® code describing it nor any concrete proof that the medical intervention is even useful. On July 16, however, Palmetto GBA did exactly that when it posted a policy update for percutaneous endovascular cardiac assist procedures and devices.

Effective for dates of service on or after Sept. 1, 2011, the jurisdiction 1 Part B MAC will cover the percutaneous insertion of an endovascular cardiac assist device and the device itself.

Coverage will be allowed for (but not exclusively) the following ICD-9-CM codes:

• Cardiogenic shock, reported with 785.51
• Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following:
  • 428.21 Acute systolic heart failure
  • 428.23 Acute or chronic systolic heart failure
  • 428.41 Acute combine systolic and diastolic heart failure
  • 428.43 Acute or chronic combined systolic and diastolic heart failure
  • 429.4 Functional disturbances following cardiac surgery
  • 997.1 Cardiac complications, not elsewhere classified

When submitting a claim to Palmetto for an endovascular cardiac assist procedure, report CPT® 33999 Unlisted procedure, cardiac surgery and enter “Impella” or “Tandem Heart” in item 19 of the CMS-1500 claim form or its electronic equivalent.

Source: Palmetto GBA

July 26th, 2012

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Move Over Obsolete Pain Management Coding

Part 1: Make room for the latest in CPT® coding.

By Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, and G.J. Verhovshek, MA, CPC

CPT® 2012 brings important changes to pain management coding. In the first of this two-part series, we’ll:

• Review the revised coding guidelines for sacroiliac (SI) joint injection.
• Clarify the methodology for determining when to use the “open” versus “percutaneous” codes for disc procedures, and corresponding changes to code 62287.
• Explain how to code the use of a catheter for a single epidural injection.
• Go over the new codes for facet joint nerve destruction.

SI Joint Injections Include Imaging Guidance

Code 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed has been revised for 2012 to include image guidance by fluoroscopy or computed tomography (CT) to confirm intra-articular needle positioning. Arthrography is also included, when performed. The corresponding radiology code (73542) has been deleted, and a new parenthetical note directs providers to use 27096 for arthrography. CPT® continues to direct providers to append modifier 50 Bilateral procedure for bilateral injections.

For example: The physician performs a right SI joint injection for sacroiliitis with 6 mg of steroid and 1 mL of 0.5 percent local anesthetic. Intra-articular needle placement was verified fluoroscopically with an injection of 0.5 mL low osmolar contrast. In this case, physician coding would be 27096-RT x 1 with a diagnosis of 720.2 Sacroiliitis, not elsewhere classified. Modifier RT indicates that the injection occurred on the right side.

Per CPT® Assistant (April 2004), CPT® 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) historically has been reported for an SI joint injection without image guidance; however, a parenthetical note in CPT® 2012 now instructs, “If CT or fluoroscopic imaging is not performed, use 20552 [Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)].”

Note: Medicare HCPCS Level II codes G0259 Injection procedure for sacroiliac joint; arthrography and G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography, used for ambulatory surgical centers and hospital outpatient place of service (POS), are unchanged for 2012.

Code 62287 Now Specifies Needle-based Procedures

CPT® code 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar has been revised to specify a needle-based procedure that may include an endoscopic approach. The procedure removes part of the nucleus pulposus, the gel center, from a herniated disk, to decrease pressure on a spinal nerve root and relieve pain.

Code 62287 now includes fluoroscopic guidance, as indicated by the revised code descriptor. Also included and not separately reportable are percutaneous aspiration with the nucleus pulposus (62267), discography injection (62290), and diagnostic/therapeutic lumbar injection (62311). You should continue to report 62287 as a single unit of service for “single or multiple levels,” and only for the lumbar spine.

The “Spine and Spinal Cord: Injection, Drainage or Aspiration” section guidelines now clarify the difference between indirect versus direct visualization. The use of an endoscope to perform a procedure does not determine the procedure coding; rather, the physician’s visualization of the disc, spinal cord, and neural space does.

The new guidelines indicate, “Percutaneous spinal procedures are done with indirect visualization (e.g., image guidance or endoscopic approaches) and without direct visualization (including through a microscope)” and “Endoscopic assistance during an open procedure with direct visualization is reported using excision codes (e.g., 63020-63035).” For a non-needle-based technique for percutaneous decompression of nucleus pulposus of intervertebral disc, CPT® directs you to 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic and 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.

For example, for percutaneous L4-L5 discectomy (PLD) with aspiration under fluoroscopic guidance for L4-L5 bulging disc, physician coding is 62287 (one unit of service) with a diagnosis of 722.10 Lumbar intervertebral disc without myelopathy.

For bilateral L4-L5 percutaneous decompressive laminectomy under fluoroscopic guidance, and epidurogram confirmation for central lumbar stenosis with neurogenic claudication, the proper coding is 0275T (single unit of service) with 724.03 Spinal stenosis; lumbar region, with neurogenic claudication.

In a final example, endoscopically assisted open hemilaminectomy with right L4 nerve root decompression for L4-L5 disc herniation would be reported 63030-RT and 722.10.

Code Diagnostic/Therapeutic Injections by Location, Duration

CPT® section guidelines and code descriptors for 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic and 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) have been revised, to include injection(s) that may involve threading a catheter into the epidural space, injecting substances at one or more levels, and removing the catheter on the same calendar day.

If the catheter is left in place to deliver substance(s) over a prolonged period (i.e., more than a single calendar day), either continuously or via intermittent bolus, report instead 62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic or 62319 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), as appropriate.

Some physicians use a catheter for cervical epidural injection(s) via the intralaminar approach at C7-T1 due to increased risk of intravascular injection with transforaminal epidural injections in the upper cervical levels. Alternately, physicians may need to use a catheter via a caudal approach to access the lower lumbar spinal levels if the patient has spinal hardware or previous laminectomy surgery. In either of these scenarios, regardless of the number and/or levels of injections, if the catheter is removed following the epidural injections (on the same calendar day), the compliant coding would be 62310 or 62311, not 62318 or 62319.

Final code choice is based on the region at which the needle or catheter entered the body (e.g., lumbar). The procedures should be reported only once when the substance injected spreads or the catheter tip insertion moves into another spinal region. For example, report 62311 one time for injection or catheter insertion at L3-L4 with substance spread or catheter tip placement into the thoracic region.

Report Facet Joint Destruction per Joint, Not per Injection

With the deletion of 64623-64627, coding for paravertebral facet join destruction is now based on destruction of the sensory innervation to each facet joint, not per facet joint nerve, as in the past:

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

+64634 each additional facet joint (List separately in addition to code for primary procedure)

64635 lumbar or sacral, single facet joint

+64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Image guidance (fluoroscopy or CT) is now required, and is no longer separately billable with either 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) or 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation. Facet joint nerve destruction continues to be considered a unilateral procedure; you may append modifier 50 for bilateral facet joint nerve destruction.

For example, to describe radiofrequency ablation of the C3, C4, and C5 medial branches, you would report 64633, 64634 because the sensory innervation to two facet joint levels, C3-C4 and C4-C5, was neurolysed. For bilateral L3-L4, L4-L5, and L5-S1 facet joint neurolysis (i.e., L2, L3, and L4 medial branches and L5 dorsal ramus), correct coding would be 64635-50, 64636-50 x 2 units of service (or, depending on your payer, 64635-LT Left side, 64635-RT and 64636-LT x 2, 64636-RT x 2).

Note: Continue to report pulsed radiofrequency ablation (which is not considered a method of destruction) using an unlisted procedure code (64999 Unlisted procedure, nervous system).

Next month, we’ll discuss revised combination codes for pump refill and programming, coding methodology changes for “simple” versus “complex” neurostimulator programming, and related concerns.

Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, is owner of MJH Consulting in Denver, Colo.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

April 1st, 2012

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Spine Reimbursement Sees a Major Impact

2012’s bundling of procedures and assigning of “experimental” T codes can hamper provider reimbursement.

By Barbara Cataletto, MBA, CPC

Changes to CPT® 2012 spinal codes and coding guidelines have an important impact on reimbursement, new technologies, and the advancement of patient care. Let’s review the changes you’ll need to know to properly document and code these surgical cases.

63030 Not for Minimally Invasive Lumbar Decompressions

Compared to 2011, you’ll notice a discreet difference in the coding requirements for decompressions of the spine. Discectomy, hemilaminectomy, and interspace decompression now require greater detail about the surgical approach.

For example, 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar now describes an “open” procedure only (as does 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical). You may no longer report 63030 for minimally invasive (i.e., endoscopically assisted) lumbar procedures, as in previous years. Instead, 62287 and 0275T now cover percutaneous and endoscopic approaches:

• 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
• 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Note that 62287 and 0275T bundle (include) many related procedures, such as fluoroscopy, imaging, discogram, etc. The bundled services may not be coded separately. The codes also describe procedures performed at either single or multiple levels; 0275T further describes either unilateral or bilateral procedures.

When selecting among 63030, 62287, and 0275T, you must review documentation language carefully to differentiate the approach and find the specific terminology necessary to support the chosen code. Look for terms such as “percutaneous,” “cannula,” “fluoroscopy,” “tubular,” “intralaminar,” “port incision,” and “endoscopic” to identify decompression by minimally invasive technique as described by 0275T and 62287. Further clarification is required to determine a needle-based approach (62287) versus a non-needle-based approach (0275T). The language here is very specific.

Minimally Invasive Fusion Now a Category III Procedure

Descriptors for 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) have been revised (removing “without”) for 2012 to require that fusion include a transverse technique. This is another critical change. To report a minimally invasive approach, the coder must now look to Category III codes:

0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic

0221T lumbar

+0222T each additional vertebral segment (List separately in addition to code for primary procedure)

As evidenced by the code descriptors, 0220T-0222T include fusion as well as instrumentation, grafting, etc. Prior to this year, these procedures have been coded separately in addition to 22610 and 22612; in 2012, the new codes cover everything.

Understand the T code Challenge

Category III CPT® codes, also called temporary codes or T codes, represent emerging medical technologies that have not yet been approved by the U.S. Food and Drug Administration (FDA). Unfortunately, payers often don’t acknowledge T codes as a viable code set, claiming that the procedures are experimental and not covered. To make matters worse, T codes are not assigned relative value units (RVUs). The lack of RVUs is significant because it signals to payers that a procedure or service is experimental, unconventional, and/or an unacceptable medical treatment. This could mean that effective procedures and services assigned T code status never “catch on,” due to a lack of reimbursement.

As an example, there are difficulties using T codes for pre-authorization, submission, and payment for services going back to the development and implementation of artificial spinal disc surgery. The artificial disc coding and reimbursement example amply illustrates how T code status has nearly destroyed the artificial disc procedure as an adjunct procedure to the spine surgeons’ repertoire.

In 2005, practices using unspecified procedure codes to report artificial disc procedures began using new Category III codes 0090T-0092T (total disc arthroplasty). Payers began treating these procedures as experimental. Years later, even now that CPT® directs coders to use 22856 (cervical) and 22857 (lumbar) to report artificial discs, many payers refuse to yield and pay for the procedures—for the most part due to past medical determinations.

In reviewing the 2012 CPT® changes, we see that several established spinal procedures have now been transferred to T codes. As mentioned, these include endoscopic discectomy (lumbar, 0275T; as well as 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic) and facet fusion (thoracic and lumber, 0220T-0222T; as well as 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical). Both endoscopic discectomy and facet fusion are widely accepted surgical procedures, with a significant history of success within the spine community. Surgeons performing these minimally invasive procedures (and facilities offering them) will likely feel a significant economic crunch with the shift from the traditional CPT® Category I code submission to T code submission.

Some payers understand the difficulties posed by T codes and have responded by providing coverage and reimbursement advisories on their websites, or may engage in “pre-surgical” discussions regarding coverage and reimbursement. Whenever there’s doubt, it’s best to be proactive and communicate directly with your payer representatives.

Proactive and cooperative communications will reduce post-surgical denials. Physicians will play a key role in educating and encouraging carriers to approve procedures if they can communicate effectively about the medical benefits to the patient.

Don’t Give Up Reimbursement without a Fight

Practices and facilities will be required in 2012 to reauthorize any previously authorized procedures that are now reported with a T code. Practices that do not confirm authorization may find themselves—as they have in the past with the artificial disc procedures—receiving denials for what are suddenly considered to be experimental or noncovered procedures.

Setting the standard for reimbursement if preauthorization is granted is a secondary challenge. Even with preauthorization and proven reimbursement history for endoscopic discectomy and minimally invasive facet fusion, the practice or facility will face challenges. T codes generally result in an immediate denial, regardless of approval status, and require in-depth appeals and audits on a regular basis. The ability to navigate these challenges requires continued communication via the appeals process. Practices will be forced to provide supportive documentation of the preauthorization, previous payment history for similar procedures, and a “stick to it” attitude toward an acceptable reimbursement solution.

One of the best defenses is a great offense. When dealing with T codes, pursue payer authorization in writing, inclusive of the CPT® codes and the patient’s diagnosis and name, specific to the individual case. This basic document is often considered unnecessary until the denial is received, and getting it up front will save a great deal of effort.

Fortunately, in the case of endoscopic discectomy and/or minimally invasive facet fusion, a practice or facility may look to historic payments from codes 63030, 22610, and 22612 to support the reimbursement levels they expect for the T codes that now apply. Review practice reporting to identify payment trends (both highs and lows) to develop an acceptable fee range for these procedures in your geographic area. This will be helpful in formulating and supporting reimbursement appeals.

Industry is not likely to embrace technologies if surgeons, unsure of reimbursement, are hesitant to perform new procedures. This may hurt patients the most. Developing technologies should involve open discussions about medical necessity, CPT® applications, and reimbursement issues during the research and development phase to reduce the possibility of undesirable or unacceptable coding and reimbursement results. Sharing in new developments requires commitments from industry, physicians, patients, and insurers if we are to continue the process of improved medical treatments and medical successes.

Barbara Cataletto, MBA, CPC, is CEO of Business Dynamics LLC and the founder and CEO of CaseCoder™.

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J1-MAC Updates Percutaneous Endovascular Cardiac Assist Coverage

Effective for dates of service on or after Sept. 1, 2011 Palmetto GBA will cover the percutaneous insertion of an endovascular cardiac assist device and the device itself.

“The impella has the capacity of being inserted into the heart from a peripheral location (femoral/axillary/iliac artery). The location of insertion is dictated by the patient anatomy. While femoral artery insertion is the most common, the axillary, iliac or subclavian arteries may provide more appropriate access when peripheral vascular disease or small femoral vessels are present,” Palmetto GBA says in an article (updated Oct. 5) posted on its website.

According to Palmetto GBA, “The literature does not clearly demonstrate when this approach is most useful,” but the jurisdiction 1 Medicare Administrative contractor (J1-MAC) will allow coverage for (but not exclusively) the following ICD-9-CM codes:

• 785.51  Cardiogenic shock
• Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-9-CM codes:
  • 428.21  Acute systolic heart failure
  • 428.23  Systolic heart failure, acute on chronic
  • 428.41  Acute combined systolic and diastolic heart failure
  • 428.43  Acute on chronic combined systolic and diastolic heart failure
  • 429.4    Functional disturbances following cardiac surgery
  • 997.1    Cardiac complications not elsewhere classified

There aren’t any CPT^® codes that accurately describe endovascular cardiac assist procedures. To report an endovascular cardiac assist procedure, Palmetto GBA requests providers to:

• Submit CPT^® code 33999 Unlisted procedure, cardiac surgery.
• Enter the word ‘Impella’ in item 19 of the CMS-1500 claim form or its electronic equivalent.

October 14th, 2011

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