Cranial Tongs with ACDF

Question:

Are we able to report CPT code 20660 for the application of cranial tongs during an anterior cervical discectomy and fusion procedure? The surgeon documented the tongs were applied and removed during the operative case.

Answer:

Thank you for your inquiry. CPT code 20660 is the correct code for the application of cranial tongs. The full definition is “Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)”. First, in reviewing the code, please note that the code has a ‘separate procedure’ designation. This means that the work associated with this CPT code is an integral part of a more extensive procedure. This means that CPT code 20660 is not reportable with CPT code 22551 “Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2” (aka ACDF) which is reported for the anterior cervical discectomy and fusion code. The use of a tongs or head holders, etc. for intra-operative positioning of the head is inclusive to any spinal procedure.

Additionally, the lay description published in Encoder Pro includes the work of applying skull traction tongs; this inclusion in the description of the procedure and the separate procedure designation preclude the surgeon from reporting CPT code 20660 in addition to the ACDF procedure code.

Typically the codes associated with halo application are reportable when the halo is applied as a stand-alone procedure or the halo is applied for longer term stabilization meaning the patient leaves the operative suite with the halo applied.

*This response is based on the best information available as of 03/02/17.

Coding With 27193

Question:

My coder just said they deleted 27193 and replaced with 2 small no global period codes? Is that correct?

Answer:

They didn’t really replace it with 2 codes, they replaced 27193 with 27197…both codeswithoutmanipulation. They replaced 27194 with 27198, both codeswithmanipulation.

Notice the difference in the language for the non-manipulative treatment:

DELETED: 27193 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation without manipulation was replaced with

NEW: 27197 Closed treatment ofposteriorpelvic ring fracture(S), dislocation(S), and diastasis or subluxationof the ilium, sacroiliac joint, and /or dislocation(S) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation.

Note that both new codes have 0 global days, a big change for the 90 day global period of the deleted codes. There is also a notation thatevaluation and managementcodes should be used in place of the global code to report the closed treatment of ONLY anterior pelvic ring fracture(s) and or dislocation(s) pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation.

*This response is based on the best information available as of 02/16/17.

Replacement Code for “Interbody Cage for Disc”

Question:

I see that CPT code 22851 – Application of intervertebral biomechanical device(s) to vertebral defect or interspace was deleted in 2017. What code do I use in 2017 for placement of an interbody cage for disc that does not have integral fixation and is being used for fusion? I see the new codes 22853 and 22854 both say with integral anterior instrumentation device for anchoring.

Answer:

Three codes have been added to CPT 2017:

• 22853 is used for interbody device insertion, with fusion, with or without integrated anterior fixation
• 22854 is used for interbody device insertion for corpectomy, with fusion, with or without integrated anterior fixation
• 22859 is used for interbody device insertion without fusion

Your options will be 22853 or 22854, depending on whether performing corpectomy. 22853 and 22854 both say “with integral anterior instrumentation for device anchoring when performed.”If you do not use integrated fixation, it is still the same codes. If you use a separate plate, that would be reportable when specific criteria are met (e.g. the plate crosses the interspace, can provide independent stabilization, and can be used with any other type of interspace device.)

*This response is based on the best information available as of 01/05/17.

Acromioclavicular Joint Billing

Question:

When our physician performs an injection into the acromioclavicular (AC) joint of a patient in the office, can we bill 20610 for a large joint arthrocentesis? I say yes because it is in the shoulder, which is listed as an example large joint in the code descriptor.

Answer:

No. The correct code to bill in this case would be 20605 for an intermediate joint. Although the AC joint is between the shoulder and the clavicle, it is considered an intermediate joint. If you look at the example intermediate joints in the descriptor for 20605 they include: temporomandibular, acromioclavicular, wrist, elbow or ankle, or olecranon bursa. The example large joints listed for code 20610 include: shoulder, hip, knee, subacromial bursa. If the physician performs the AC injection utilizing ultrasound guidance with permanent recording and reporting, then you should report code 20606 instead of 20605. And don’t forget to bill the HCPCS II code for the medication itself.

*This response is based on the best information available as of 10/27/16.

Reimbursement: Assistant Surgeon

Question:

What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? What about a PA or nurse practitioner who assists at surgery?

Answer:

An assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code.

Modifier 80 (modifier 82 for an assistant surgeon in an academic setting when a qualified resident is not available) is appended to any CPT code the assistant participates in. Medicare reimburses 16% of the allowable for the assistant surgeon (modifier 80 or 82) and multiple procedure/bilateral procedure reductions also apply. The primary surgeon’s reimbursement is not affected. In an assistant surgeon scenario, the assistant need not and should not dictate a separate note. However, it is critical that the primary surgeon document in his/her note, specifically what the assistant did. Stating an assistant was needed because the case was complex is not sufficient. The primary surgeon must state what the assistant did, for example, assisting with positioning and retraction, surgical closure, etc. When a physician assistant or nurse practitioner assists in surgery, Medicare reduces their reimbursement by 15% of what a physician would be paid for assisting, and Medicare directs us to designate a PA or NP service using modifier AS (instead of modifier 80).

Keep in mind, Medicare does not allow payment for assistant support for all surgical CPT codes. For private payers, coding guidelines and payment rates may vary.

*This response is based on the best information available as of 09/29/16.

ICD 10: Aftercare Z Codes or 7th Character Code?

UPDATED

Question:

Patient has been seen in office during the global period after a rotator cuff repair for a sprain. No X-rays were taken. Internally we will record 99024. Would we assign Z47.89 or the sprain code to 99024?

Answer:

Thanks for your inquiry as your question gives us an opportunity to address documentation requirements and how sprains and strains are delineated in ICD-10-CM.

First, under ICD-10-CM descriptions, an acute injury to the rotator cuff muscle or tendon is described as a “strain”, under the subcategory S46,01- , not as a “sprain.”  Although there is also an ICD code for sprain of the rotator cuff capsule, S43.42-, that is not the structure that typically injured.

If you’ve determined that the problem is an injury, you will look to the S codes; if it is a chronic or recurrent problem, you will look to the M codes.

The ICD-10-CM options for a rotator cuff strain are:S46.011- Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulderS46.012- Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulderS46.019- Strain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder

Ideally the physician will document whether the strain affects the right or left shoulder; use of the unspecified code is reserved for cases when the laterality is not described.

If the patient is seen in the global period for the injury, then the 7th character D is applied to indicate routine healing following active treatment of an injury.

If the surgery was done to treat a chronic or degenerative condition coded from the M chapter, you will report Z47.89, Encounter for other orthopedic aftercare, provided the follow-up is uncomplicated.

*This response is based on the best information available as of 02/4/16.