Coding and Reimbursement

How do I code for a 360 degree labral repair?

Code 29806 can be used for anterior, inferior, and/or posterior labral repairs.  The code can only be used once.  It cannot be used for each area.  If the surgeon documents and can justify that the repair required more work than what they would consider standard for a labral repair or will require more work postoperatively, then a modifier 22 can be added. 

If a superior labral repair is done, this is coded separately using code 29807.

How do I code for a superior capsular reconstruction?

There is no code for superior capsular reconstruction.  The best option is to code for other procedures that are done concomitantly and documented in the surgical report.  For example, if a rotator cuff repair was done, even a partial repair, then code 29827 is used.  If the criteria for debridement is met, then 29823 should be coded (see criteria below). Additionally, a modifier 22 may be added to other codes that are used if felt to be appropriate and supported by the surgical documentation.

If no other procedures are done or documented, the final option would be to code 29999 and reference a similar code in terms of work such as 29827 (preferable) or 29806. 

Can I bill for a biceps tenotomy as a separate code?

There is no separate code for arthroscopic biceps tenotomy.

Biceps tenotomy can be considered one structure addressed to satisfy the requirements of code 29822 or 29823, if those codes are appropriate to bill based on documentation and other codes concomitantly coded.

How do I bill for a Remplissage procedure?

There is no code for a Remplissage procedure.  The best option is to code for other procedures that are done concomitantly and documented in the surgical report.  A modifier 22 may be added to other codes that are used if felt to be appropriate and supported by the surgical documentation.

What are the requirements to bill an arthroscopic loose body removal?

The criteria for loose body removal will change starting in 2021.  Below is the new language in the CPT book.  The “arthroscopic cannula” referred to is the arthroscope cannula diameter, not the cannula of the working portals.

Arthroscopic removal of loose body(ies) or foreign body(ies) (ie, 29819, 29834, 29861, 29874, 29894, 29904) may be reported only when the loose body(ies) or foreign body(ies) is equal to or larger than the diameter of the arthroscopic cannula(s) used for the specific procedure, and can only be removed through a cannula larger than that used for the specific procedure or through a separate incision or through a portal that has been enlarged to allow removal of the loose or foreign body(ies).

29822 (Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]))

29823 (Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]))

  • 29823 will decrease in wRVUs from 8.36 to 7.98
  • 29822 will decrease in wRVUs from 7.60 to 7.03

29826
ASES, AOSSM, AANA, and AAOS are actively engaged with BCBS in ongoing discussions and literature review on the denials of 29826.  The following letter has been sent to health care administrators at Anthem BCBS and AIM Specialty Health.

https://www.aaos.org/globalassets/advocacy/aaos-msk-letters-to-anthem-and-aim.pdf


New Updates for 2021 E/M Billing:

The following AAOS website reviews changes in E/M Coding for 2021:

https://www.aaos.org/aaosnow/2020/apr/managing/managing01/

Current Procedural Terminology Codes (CPT Codes)

CPT Codes are used in medical billing to represent unique medical procedures and are made up of two parts

  • CPT Description: The description of a CPT code has been verified by the CPT Editorial Panel.  The CPT Editorial Panel is overseen by the American Medical Association. 
    • CPT Editorial Panel
      • AMA Panel that Revise, Update and Modify CPT Codes
      • 17 Members (11 Physicians from Med Spec Societies, BCBS, AHIP, AHA, CMS, 2 from CPT Health Care Professionals Advisory Committee)
      • CPT Advisory Committee
      • Meets 3 times per year
    • AAOS Representation on CPT Editorial Panel (Not all societies represented)
    • For more information on the CPT Editorial Panel: https://www.ama-assn.org/about/cpt-editorial-panel
  • CPT Value: The value of a CPT code is reviewed by the Resource Based Relative Value Scale Update Committee (RVS Update Committee or RUC).  The RUC is a part of the AMA and the committee makes recommendations to CMS regarding changes in CPT value (RVUs-see below).

Insurance payments for physician billing is most often determined by the Medicare Physician Fee Schedule.  Many commercial insurances use the Medicare payment formula as a basis for determining payment (i.e. 110% of Medicare for XYZ Insurance Company).




Relative Value Units (RVUs)
RVUs are categorized into three different types

  1. Work RVU: Reflects the time and complexity of a CPT Code
  2. Practice Expense (PE) RVU: Determined by the cost to a practice including rent and other overhead expenses
  3. Malpractice (MP) RVU: The cost of malpractice coverage required.

 

Geographic Practice Cost Indices (GPCIs)

This index is determined by your geographic location and there is a corresponding GPCI for each type of RVU(Work GPCI, PE GPCI, MP GPCI).

Conversion Factor (CF)

Is updated using a formula every year to maintain budget neutrality

To see more information regarding Medicare Fee schedules and CMS payments visit the AAOS Advocacy page at:

https://www5.aaos.org/CustomTemplates/Content.aspx?id=22519&ssopc=1

AAOS CCRC

The AAOS has active representation on both the CPT Editorial Panel and the RUC.  The AAOS CCRC has the following representation:


ASES Coding Coverage and Reimbursement Committee

The ASES has two members who are actively involved in the AAOS CCRC and represent the interests of ASES members in regards to coding and reimbursement.

Julie Bishop, MD:  ASES Representative on AAOS CCRC; CPT editorial panel alternate advisor for AAOS

Hussein Elkousy, MD:  RUC Alternate Advisor for the AAOS

Included below are some of the many responsibilities of our representatives

  • Respond to changes in policy on behalf of AAOS
  • Educational articles & courses
  • Regularly review Codex for accuracy
  • Answer AAOS member online queries
  • Work with the AAOS/ASES PACS to convey clear messaging
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