Is a Lateral Retinacular Release Separately Billable?

Question:

Our surgeon performed a reconstruction of a patella dislocation and also did an arthrotomy of the knee with a lateral retinacular release. Our surgeon wants to report 27420 and 27425. When I look at the NCCI edits, I see there is an edit between the two codes. Am I allowed to add a modifier 59 to CPT® code 27425 to indicate this is a distinct separate service?

Answer:

Thank you for your inquiry. Let’s start by taking a look at the CPT® code definitions.

27420 Reconstruction of dislocating patella; (eg, Hauser type procedure)27425 Lateral retinacular release, open

To answer, your Question:, the answer is “no, the lateral retinacular release is inclusive to CPT® code 27420 for the reconstruction of the patellar dislocation.

Why? Let’s take a look at the AAOS Global Service Data Guide for CPT® code 27420.

The following is an excerpt of procedures that are considered ‘inclusive” to CPT® code 27420 when performed during the same operative session.

• osteotomy (eg, 27457)
• arthrotomy of knee (eg, 27310, 27330, 27331)
• release of lateral retinaculum (eg, 27425)
• internal fixation
• chondroplasty of patella (eg, 27437)
• diagnostic arthroscopy of knee (eg, 29870)

You already note the NCCI edit between 27420 and 27425; adding modifier 59 to CPT® code 27425 represents incorrect coding.

*This response is based on the best information available as of 12/03/20.

SI Joint Injection Help

Question:

My physician performed an SI joint injection in the ASC under ultrasound guidance and wants to bill 27096 and 76942. Is this correct? The description of the codes say imaging is included.

Answer:

No, this is not correct; you are correct to catch the inclusion of the imaging statement.

CPT code 27096 is defined as includingfluoroscopic or CT guidance, but not ultrasound (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed).

Per CPT guidelines, if ultrasound is used instead of fluoroscopy or CT, report a trigger point injection code 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) and 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). CPT code 20552 is reported one time, whether the procedure is performed as a unilateral or bilateral procedure. Remember, CPT code 76942 has a professional and technical component; in the ASC setting you will append modifier 26 assuming the procedure note includes the required documentation for US guidance.

In answer to your question based on the ASC place of service, assuming documentation and medical necessity are present, the correct codes are:2055276942-26

If the procedure is performed in the office setting and you own the equipment, you may report 76942 without a modifier if the documentation supports the service.

Note: Some payor policies may deny payment of the US guidance ( CPT code 76942) with CPT code 20552.

*This response is based on the best information available as of 10/29/20.

Subacromial Decompression (29826)

Question:

Our surgeon frequently documents in the procedure title that an arthroscopic subacromial decompression was performed.  We are billing 29826 and are receiving denials from one particular payor stating that the documentation does not support the service.  I am looking at the operative notes associated with these denials and see that in none of the cases did the surgeon document any bony work. Is this required to report this code?

Answer:

Thank you for sharing your experience.  We heard of these denials years ago, so we appreciate  your sharing this information that a payor is again looking  at this code for supportive documentation.  To answer your Question:, yes, CPT code 29826 includes work on the acromion.

Note in the CPT code description, partial acromioplasty is listed as part of the procedure;  this is the ‘bony work’ in your inquiry.

29826  Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)

Soft tissue work alone does not meet the definition of this CPT code. Typically, we see documentation similar to ‘an acromioplasty was performed  and reshaped to a type 1 acromion.’ This type of documentation will support the required work for the acromioplasty.  Removal of osteophytes or co-planing of the acromion does not support the partial acromioplasty requirement.

*This response is based on the best information available as of 10/15/20.

Modifier 78: Global Period Impact

Question:

We have a patient who had knee surgery and required a return to the operating suite for treatment of a complication during the global period. We will bill the second surgery with a modifier 78. My supervisor is saying the aftercare needs to be extended another 90 days because the surgeon had to return the patient to the operating suite for the same anatomic site.

I have always understood that modifier 78 does not restart the global period, but now am Question:ing myself. Will you please provide guidance?

Answer:

Thanks for contacting KZA with your inquiry.  You are correct!  Modifier 78 (Unplanned Return To The Operating/Procedure Room By The Same Physician Or Other Qualified Health Care Professional Following Initial Procedure For A Related Procedure During The Postoperative Period) does not restart the global period, and will be subject to a  reduction in reimbursement for the portion of the global period which overlaps with the original surgery.

CMS’s reimbursement formula for a procedure with a modifier 78 does not include payment for post-operative days, thus the global days stay with the original procedure.

I am including an excerpt from a source citation from Novitas (an example Medicare MAC) on this topic; the concept applies to all Medicare claims:

Facts

• An operating room (OR) is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to the OR).
• Modifier 78 allows for the intraoperative percentage only of major or minor procedures (010 or 090 global periods).
• A new postoperative period does not begin when using modifier 78.
• Medicare allows codes with global surgery indicators of XXX and ZZZ in the Medicare Physician Fee Schedule Database separately without modifier 78.

Source:https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144546accessed 12/23/20

*This response is based on the best information available as of 10/01/20.

Trigger Finger Injection

Question:

Which CPT code is used 20550 or 20551 for a trigger finger /A1 pulley injection?

Answer:

CPT code 20550 defines an injection to a single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”).

CPT code 20551 defines an injection to single tendon at the origin/insertion site.

Trigger finger injections are most commonly given to the flexor tendon, supporting CPT code 20550.

*This response is based on the best information available as of 09/03/20.

Meniscal Repair and Meniscectomy

Question:

Can I bill for a medial meniscus repair and a lateral meniscus meniscectomy done on the same knee? I see CMS has an NCCI edit between the two codes, 29881 and 29882.

Answer:

Yes, you may report both codes and append modifier 59 to indicate the procedures were performed on different anatomic sites. CPT, AAOS, and NCCI consider the compartments of the knee to be distinct anatomic structures.

*This response is based on the best information available as of 03/05/20