Published 3/11/2024
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Marissa Clemmer, CPC, CCS, CPMA, CPB, CANPC, CPEDC
Editor’s note: AAOS partners with KZA on the organization’s coding education, and KZA often provides content for AAOS Now. For more information, visit aaos.org/membership/coding-and-reimbursement.
This column addresses recently asked Current Procedural Terminology (CPT) coding questions posed by orthopaedic surgeons, practice managers, and staff.
Can CPT code 22214 (posterior osteotomy of spine, lumbar) and code 22325 (posterior open reduction of vertebral fracture, lumbar) be coded together at the same interspace L4-L5? There is a National Correct Coding Initiative (NCCI) edit of “1” between these two codes, so should modifier 59 (Distinct Procedural Service) be used because the fracture is considered a “separate injury”?
No, it is not accurate to report a spine osteotomy code (i.e., 22214) and a spine fracture code (e.g., 22325) together for procedures at the same spinal level (e.g., L4-L5) when performed via the same incision/approach (i.e., posterior/posterolateral), and modifier 59 would not be applicable here. If the patient has an acute fracture being addressed, then report the fracture repair code. The osteotomy codes are used for correction of spinal deformities, not repair of spinal fractures. Do not forget that other applicable codes such as arthrodesis, instrumentation, and bone graft may be separately reported.
Can the code for negative pressure wound therapy (wound vac) be applied when it is used on both open and closed wounds?
Yes, this is correct. According to the CPT coding guidelines, a wound vac code (97605 to 97608) may be reported any time one is placed.
However, Medicare’s NCCI payment guidelines prevent reimbursement of a wound vac code when the device is placed on a closed wound (e.g., skin graft placed, incision closed). For Medicare and other payers following Medicare’s NCCI edits, separately reporting the wound vac would not be allowed. KZA recommends checking the Centers for Medicare & Medicaid Services Local Coverage Determination and private payer policies that may limit coverage to use with open wounds.
Be sure to document whether the device placed is a durable medical equipment (DME) product (codes 97605 to 97606) or a non-DME product (97607 to 97608) to ensure correct coding for the device.
Can dry needling (CPT codes 20560 to 20561) be performed in the office?
Yes, dry needling can be performed in the office and usually is performed in that setting, but whether it will be paid is a different story. Check the specific payer policies for coverage criteria for this service, as many payers considered it “noncovered.”
Peer-to-peer review calls are often required with insurance companies for patient treatment/surgery authorizations. This is very time consuming. Is there a CPT code to bill insurance companies for this service?
Unfortunately, at this time, there is not a CPT code for a peer-to-peer review call. This service is considered part of the administrative work associated with patient care and not separately coded.
When biological augmentation is done for repairs using an inducive collagen implant, is there a modifier or CPT code for the substance in addition to the rotator cuff reconstruction itself?
For physician CPT coding, there is no additional reporting for the biologic augmentation material used. The ambulatory surgery center or hospital may bill for the implant on the facility claim; however, it is not appropriate for the physician to bill.
If the procedure is done in an open manner, with the use of biologic material, report 23420, Reconstruction of complete shoulder (rotator) cuff avulsion, chronic, (includes acromioplasty).
If the procedure is done arthroscopically, and the surgeon did not perform a repair of the rotator cuff, report an unlisted arthroscopy code 29999 (Unlisted procedure, arthroscopy) referencing 29827 as a comparable code. If a torn rotator cuff is repaired arthroscopically and is supplemented with biologic augment, both AAOS and KZA recommend using CPT code 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) with modifier 22 for the additional work.
Again, the material is not separately reportable since the facility (not the physician) incurred the expense for the implant.
A surgeon performed a repair of an Achilles tendon, excision of Haglund’s deformity, and a retrocalcaneal bursectomy. Can the bursectomy be coded in addition to the repair and excision of the Haglund’s deformity?
The excision of the retrocalcaneal bursectomy is not separately reportable. This work is inclusive to the excision of the Haglund’s deformity. The Achilles tendon repair is separately reported in this scenario.
Keep up with coding changes
KZA invites AAOS members to attend an AAOS coding and reimbursement workshop in 2024. To learn more, visit karenzupko.com/orthopaedics.
Marissa Clemmer, CPC, CCS, CPMA, CPB, CANPC, CPEDC, is a consultant with KZA and an instructor at the AAOS reimbursement and coding workshops.