Medicare's National Correct Coding Initiative (NCCI) guidelines for arthroscopy are crucial for healthcare providers and coders to understand. These guidelines ensure that billing for arthroscopic procedures aligns with Medicare's rules to prevent improper payments due to incorrect coding.
Understanding NCCI
The NCCI, developed by the Centers for Medicare & Medicaid Services (CMS), aims to prevent improper payments when coding multiple procedures. This initiative includes a set of coding policies and edits that determine how certain services can be billed together.
Arthroscopy and NCCI
Arthroscopy is a minimally invasive surgical procedure on a joint. For Medicare billing, specific NCCI edits apply to arthroscopy procedures, which can affect reimbursement.
Surgical arthroscopy encompasses diagnostic arthroscopy, which cannot be reported separately. When a diagnostic arthroscopy progresses to a surgical arthroscopy during the same patient visit, only the surgical arthroscopy is eligible for reporting.
When arthroscopy is used as a preliminary 'scout' procedure to examine the surgical area or determine the severity of the disease, it cannot be reported on its own. However, if a diagnostic arthroscopy results in the choice to conduct an open surgery, the diagnostic arthroscopy might be reported independently. In Medicare billing, the modifier -58 can be used to show that the diagnostic arthroscopy and the subsequent non-arthroscopic therapeutic procedures were either staged or planned. The medical records must document the medical necessity of the diagnostic arthroscopy.
Arthroscopic to Open Procedures: Coding Implications
When an arthroscopic procedure is changed to an open procedure, only the open procedure is eligible for reporting. In cases where a surgical arthroscopic procedure is converted to an open procedure, neither a surgical nor a diagnostic arthroscopy code should be used in conjunction with the code for the open procedure.
Except for procedures involving the knee and shoulder, arthroscopic debridement cannot be independently reported when it is performed on the same joint during the same patient encounter as a surgical arthroscopy procedure. Review Chapter 4 of the Medicare NCCI manual to discover when arthroscopic debridement of the shoulder may be reported in addition to other arthroscopic procedures on the same shoulder.
There are instances where both a surgical arthroscopy and an open procedure may be reported together. For example, an arthroscopic meniscus repair (29882) may be reported in addition to an open collateral ligament repair (27405) of the knee. A situation that would apply to this section of the blog would be when a surgeon attempts an arthroscopic rotator cuff repair and must convert to an open repair; under those circumstances, only the code for the open repair is reported.
CPT Codes in Focus: What You Need to Know
The CPT codes 29874 (Arthroscopy, knee, surgical; removal of loose body or foreign body, for example, osteochondritis dissecans fragmentation, chondral fragmentation) and 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)) should not be used in conjunction with other knee arthroscopy codes (29866-29889).
Except for two specific cases, the HCPCS code G0289 (Arthroscopy, knee, surgical; involving removal of loose body, foreign body, debridement/shaving of articular cartilage during a different surgical knee arthroscopy in another compartment of the same knee) can be used alongside other knee arthroscopy codes
CPT codes 29880 (Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) and debridement/shaving of articular cartilage (chondroplasty) in the same or different compartments, if done) and 29881 (Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) and debridement/shaving of articular cartilage (chondroplasty) in the same or different compartments, if done) already cover debridement/shaving of articular cartilage in any compartment. Therefore, HCPCS code G0289 can only be reported in conjunction with CPT codes 29880 or 29881 if it is for the removal of a loose body or foreign body from a different compartment of the same knee.
The HCPCS code G0289 should not be used for the removal of a loose body or foreign body, or for the debridement/shaving of articular cartilage, if these procedures are conducted in the same compartment as another knee arthroscopic procedure.
Procedures for shoulder arthroscopy, such as limited debridement (for example, CPT code 29822), are included even if the debridement occurs in a different part of the same shoulder than the primary procedure. In most cases, shoulder arthroscopy procedures also encompass extensive debridement (like CPT code 29823), regardless of whether it's performed in a different area of the same shoulder. However, there are three exceptions: CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) can be reported separately with CPT code 29823, but only if the extensive debridement is carried out in a distinct area of the same shoulder.
Procedures for shoulder arthroscopy, such as limited debridement (for example, CPT code 29822), are included even if the debridement occurs in a different part of the same shoulder than the primary procedure. In most cases, shoulder arthroscopy procedures also encompass extensive debridement (like CPT code 29823), regardless of whether it's performed in a different area of the same shoulder. However, there are three exceptions: CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) can be reported separately with CPT code 29823, but only if the extensive debridement is carried out in a distinct area of the same shoulder.
Knee arthroscopic synovectomy can be documented using CPT codes 29875 (Limited synovectomy, termed as 'separate procedure') or 29876 (Major synovectomy involving two or three compartments). However, a synovectomy carried out simply to 'clean up' a joint during a more comprehensive procedure on the same joint is not eligible for separate reporting.
CPT code 29875 should not be used in conjunction with any other arthroscopic knee procedure on the same (ipsilateral) knee. However, CPT code 29876 is reportable alongside another arthroscopic knee procedure on the same knee if it involves a medically necessary and reasonable synovectomy in two compartments where no other arthroscopic procedures are being performed. For instance, CPT code 29876 should not be reported for a major synovectomy when it is combined with CPT code 29880 (Knee arthroscopy, medial and lateral meniscectomy) on the ipsilateral knee, because other arthroscopic procedures besides synovectomy are being conducted in two of the three knee compartments.
Reporting Extensive Shoulder Debridement Independently (CPT code 29823)
The extensive shoulder debridement represented by CPT code 29823 can be reported separately if the debridement goes beyond the scope typically included in the main procedure. This code pertains to the arthroscopic removal of injured or diseased tissue from the shoulder joint, often used in addressing significant conditions like rotator cuff tears, labral tears, or osteoarthritis that necessitate extensive tissue removal.
When documenting extensive shoulder debridement (CPT code 29823), the specific details of the procedure are crucial. In certain situations, this code may be independently reported alongside other primary shoulder procedures. However, it's important to recognize that not every scenario justifies the independent reporting of extensive shoulder debridement. The decision to report CPT code 29823 on its own should be grounded in medical necessity and the degree of debridement conducted.
A thorough review of the operative report and relevant documentation is necessary to assess whether the level of debridement warrants independent reporting. If the debridement is minor or inherently part of another primary procedure, it shouldn't be reported separately. Adequate documentation must precisely detail the debridement's extent, demonstrating that it surpasses what is normally included in the main procedure. Such detailed documentation is key to substantiating the separate reporting of CPT code 29823.
Arthroscopy and NCCI
Arthroscopy is a minimally invasive surgical procedure on a joint. For Medicare billing, specific NCCI edits apply to arthroscopy procedures, which can affect reimbursement.
Key NCCI Guidelines for Arthroscopy
Column 1/Column 2 Code Pair Edits: These edits define pairs of HCPCS/CPT codes that should not be reported together. For example, a comprehensive arthroscopy code might not be billable with a more specific procedure code on the same joint.
Mutually Exclusive Edits: These edits prevent billing for procedures that are unlikely to be performed together on the same patient on the same day.
Modifier Usage: Under certain circumstances, modifiers can be used to bypass an NCCI edit. The most common modifier in arthroscopy is the -59 modifier, indicating that a procedure or service was distinct or independent from others performed on the same day.
Compliance is Key
It's vital for providers to adhere to these guidelines to avoid claim denials or audits. Understanding NCCI edits specific to arthroscopy can help in accurate coding and billing.
Staying Informed
The CMS regularly updates the NCCI edits, so it's important for coding professionals and healthcare providers to stay updated. These updates can include additions, revisions, or deletions to the code pairs.
Practical Tips for Providers
Regularly review the NCCI Policy Manual.
Use accurate and complete documentation to support billing.
Stay updated on changes to arthroscopy-related codes and edits.
Consult with a professional coder or billing specialist familiar with NCCI guidelines.
Navigating Medicare's NCCI guidelines for arthroscopy requires diligence and continuous education. Adherence to these guidelines ensures proper reimbursement and compliance with Medicare's billing policies, ultimately contributing to the efficient functioning of the healthcare system. Feel free to contact us directly here for any medical coding questions or needs you may have.
Check out some more of our resources such as the 2024 CPT code changes.