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Correctly code arthroplasty by identifying the type

JustCoding News: Outpatient, August 20, 2014

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One of the challenging aspects of coding arthroplasties is determining whether the procedure actually was an arthroplasty, and if so, which type.
"People often see arthroplasty and think a prosthesis is being placed, when that's not necessarily what's being done," says Ruby O'Brochta-Woodward, BSN, CPC, COSC, CSFAC, quality and data specialist for Twin Cities Orthopedics in Golden Valley, Minnesota.
Types of arthroplasty
Coders should first be aware of the various types of arthroplasty procedures and how they differ. In a fascial procedure, the physician removes osteophytes (bone spurs) from the joint surface and places a fascial membrane over the surface. The tissue can be an autograft (from the patient), but it's becoming more common to use skin substitutes and matrix grafts, according to O'Brochta-Woodward.
There are currently no specific CPT® codes to report fascial arthroplasty for many joints, she added.
Interposition involves the removal of all or part of a joint with placement of a soft tissue spacer, such as fascia, tendons, or silicone. The tissue fills the space between the bones and creates a fibrous joint. This type of procedure is most common in the carpometacarpal joints of the wrist, especially the thumb, says O'Brochta-Woodward. For an interposition of the carpometacarpal joint, coders would report CPT code 25447. Types of interposition include:
  • Arthrotomy
  • Synovectomy
  • Capsulotomy
  • Ostectomy
  • Placement of internal fixation
If the physician harvests a tendon graft from a different site through a separate incision as the interposition material, coders may also report 202924 (tendon graft, from a distance), says O'Brochta-Woodward, citing CPT Assistant January 2005. Coders must append modifier -59 (distinct procedural service) to the code as well.
If the physician harvests the tendon graft from the same incision as the arthroplasty, it is included in the base procedure.
"Incisions just to free the tendon do not constitute a separate incision," O'Brochta-Woodward says.
Suspension arthroplasty
Suspension arthroplasty is a variation of interposition where the first metacarpal is suspended to the second metacarpal to provide joint stability and prevent migration. The physician harvests the flexor carpi radialis (FCR) from the forearm through a second incision. The physician then attaches the part of the tendon still attached to the muscle belly to the second metacarpal, creating the suspension. The rest of the FCR is then often placed as the interposition graft, according to O'Brochta-Woodward.
For example, if the physician performs a tendon transfer of the extensor tendon of the forearm, coders would report 25310 for each tendon (tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon). For a transfer of a tendon in the dorsum of the hand without a free graft, they would report 26480 for each tendon.
Interposition artroplasty is becoming more common in the metatarsophalangeal joints of the foot, according to O'Brochta-Woodward. Currently it has no specific CPT code, so coders must use 28899 (unlisted procedure, foot or toes).
A resection procedure involves the excision of a portion of a joint surface.
"Coders need to read the operative report to determine what part of the bone is being removed, and how much of it," says O'Brochta-Woodward. CPT code 27122 (acetabuloplasty; resection, femoral head [e.g., Girdlestone procedure]) is an example of a resection.
Revision arthroplasty requires the removal of previously placed prosthetic components and reinsertion of new components in a single surgical procedure. Removal of the previously inserted prosthesis is included in the code. Specific CPT codes exist for shoulder, elbow, wrist, hip, knee, and ankle revisions.
Shoulder, elbow, hip, and knee revision codes are based on which components are removed and replaced, according to O'Brochta-Woodward. For example, coders would report 24371 for a revision of a total elbow arthroplasty including the allograft when performed on the humeral and ulnar component.
While single-stage revisions can be relatively straightforward to code, multi-stage revisions due to infections require multiple steps, according to O'Brochta-Woodward.
The first step is to report a complicated removal of the prosthesis, for example, code 27488 (removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee).
Coders can add 11981 (insertion, non-biodegradable drug delivery implant) if the physician inserts non-biodegradeable antibiotic beads.
"AMA considers temporary devices placed as a spacer, even if it's shaped like a prosthesis," O'Brochta-Woodward says. "The spacer is bundled into the removal code and not separately reportable."
In addition, O'Brochta-Woodward notes that there is little consistency where these removal codes may be located in the CPT Manual; they are sometimes listed under Removal and sometimes Repair.
Stage two includes the removal of the spacer/temporary implant and joint debridement. Coders will report another code with modifier -58 (staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period) appended. For the knee, the code would be 27310-58 (arthrotomy, knee, with exploration, drainage, or removal of foreign body [e.g., infection]).
If non-biodegradeable beads are removed and reinserted during this phase, code 11983 (removal with reinsertion, non-biodegradable drug delivery implant) can be reported. If there is a reinsertion of an antibiotic impregnated spacer without previously placed beads, 11981 can be reported.
Finally, coders will report a third code with modifier -58 for the final stage. For the knee, the code would be 27447-58 (arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing [total knee arthroplasty]). Removal of the spacer is included in the code, according to O'Brochta-Woodward. Coders can also append modifier -22 (increased procedural services) if the documentation supports significantly increased work.
According to the AMA, reinsertion should not be coded as a revision arthroplasty, since revision arthroplasty includes removal of the primary prosthesis and this step has already been performed.
O'Brochta-Woodward notes that there is currently no specific guidance on staged revision for shoulders, elbows, and ankles.
Reporting arthroplasty diagnoses
Coders will have to use a V code in ICD-9-CM (V54.81) when reporting aftercare for joint replacement. This code includes a note to use an additional code from V43.60-V43.69 to identify the site of the joint replacement. If submitting claims for physical or occupational therapy post-joint replacement, coders need to remember to add a code from the V43.6x series, says O'Brochta-Woodward.
Coders also need to remember V codes when reporting staged revisions. For example, when reporting ICD-9-CM code 996.49 (other mechanical complication of other internal orthopedic device, implant, and graft), coders will need to specify the joint using a code from V43.6x.
When reporting aftercare and subsequent stages, including encounters for reinsertion of a prosthesis, coders should report V54.82 (aftercare following explanation of joint prosthesis) as well as a code from the V88.2x series to specify the joint.
ICD-10-CM gives coders many more options to include specific sites, laterality (right, left, bilateral), and causes in most of the diagnosis codes, according to O'Brochta-Woodward. If no bilateral code is available, coders should use a separate code for the right and left side, according to Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM for HCPro, in Danvers, Massachusetts. If the side is not identified in the documentation, coders should assign the code for an unspecified side.
Most surgeons will document laterality somewhere in the medical record because of pre-surgery checks they must perform. Coders should carefully review the documentation for this information before assigning an unspecified code. For example, the physician may document “right knee prepped and draped in sterile fashion,” which would indicate the laterality.
Codes for orthopedic aftercare are located in category Z47 in ICD-10-CM. When reporting Z47.1 (aftercare following joint replacement surgery), coders should note instructions to use an additional code to identify the joint from Z96.6-.  
Email your questions to editor Steven Andrews at sandrews@hcpro.com.

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