February Coding Update:
Cigna Policy Updates
This month’s Cigna policy update is regarding skin substitutes and their
updated list of those that are reimbursed for ulcers. The complete policy can
be seen at here!
Diabetic Foot Ulcers
- AlloPatch Pliable®
- AmnioBand®
- Apligraf®
- DermACELLTM
- Dermagraft® EpiFix®
- Amniotic Membrane
- Grafix®
- Graft Jacket®
- Regenerative Tissue Matrix
- Integra® Dermal
- Oasis® Wound Matrix and Ultra-Layer Matrix
- Theraskin®
These are some that are considered experimental, investigational and not
proven, for any indication, and are not payable. Please see the full list by
using the weblink above:
- Amniofix® Amniotic Membrane for tendon/nerve repair
- BioDfenceTM Surgical wrap/barrier or tendon repair
- Epifix® Injectable for wound care
- Neox® Cord 1K for wound care
UnitedHealthcare Updates
Effective May 1, 2018 UnitedHealthcare will require the anatomical modifier
on all procedures performed on fingers or toes. Procedure codes reported
without the modifier will be denied. These are the assigned finger and toe
Modifiers.
Fingers
- FA Left hand, thumb
- F5 Right hand, thumb
- F1 Left hand, second digit
- F6 Right hand, second digit
- F2, Left hand, third digit
- F7 Right hand, third digit
- F3 Left hand, fourth digit
- F8 Right hand, fourth digit
- F4 Left hand, fifth digit
- F9 Right hand, fifth digit
Toes
- TA Left foot, great toe
- T5 Right foot, great toe
- T1 Left foot, second digit
- T6 Right foot, second digit
- T2, Left foot, third digit
- T7 Right foot, third digit
- T3 Left foot, forth digit
- T8 Right foot, fourth digit
- T4 Left foot, fifth digit
- T9 Right foot, fifth digit
Assistants At Surgery
Insurance carriers may require additional documentation in the operative report other than just listing the assistant at surgery for many orthopaedic surgical procedures. Even then, based on policy, it is still up to the insurance carrier to determine if the documentation supports an assistant. This is for physicians or non-physician practitioners. This is a good example of documentation to support an assistant at surgery.
I then had my assistant pull traction and internal rotation, and using a
series of reduction clamps, I reduced the fracture anatomically. This was
then held in position with a lag screw from anterior-superior to posterior
inferior. This was 3.5-mm lag screw. This held the fracture anatomically
reduced. Given the fact this is a very distal fracture fragment, it was
extremely difficult to reduce, but we were able to reduce it anatomically.
This was the reason why I used a locking plate, given the significant
distal nature of the fracture.
Aetna Meniscectomy Reminder
I had this in last month’s update, but I am sending it again this month!
Please remember that Aetna does not reimburse for arthroscopic meniscectomy, CPT codes 29880 and 29881, for degenerative meniscus tears. The documentation in your medical record must support an acute tear. Phrases like “Patient had no injury” or “MRI shows degenerative changes” does not support an acute tear. There is no possibility of appealing these cases, and you will not be paid. Aetna patients with degenerative tears can be treated as self-pay, and collecting up front is suggested.
Knee X-rays
We receive charges for knee x-rays in many ways. The coding committee at HIS created a coding tip to clarify how x-rays of the knee should be reported:
Description:
73560: Xray; knee 1 or 2 views: 73562: Xray; knee 3 views: 73564: Xray; knee 4 or more views: 73565 Xray; both knees-standing anteroposterior (AP)
Coding:
Xrays of knee(s) would be coded based on number of views performed utilizing codes as above.
Tips:
In summary, code 73565 for upright AP views of the knees is coded only if no other views are done for that examination. If additional views are done, the upright AP views of the knees is counted as an additional view of affected knee and code 73565 is not utilized. There are codes for a one/two view study, a three view study and a four or more view study of the knee, as outlined above. Remember, any code utilized should be based on medical necessity and
a physician’s order.
Examples on standing knees: “Note that code 73565 (Xray exam, both knees, standing,
Anteroposterior) should only be reported with an AP standing xray of both knees is THE
ONLY STUDY PERFORMED.
The three basic codes of the knee (73560:1-2 views, 73562: 3 views and 73564: 4 or more views) describe all other knee studies. For example: when an AP upright of both knees, plus lateral and skyline views if the right knees are performed, it would not be appropriate to report 73565. In this scenario, it would be appropriate to code 73560-LT to describe the 1 view of the left knee and 73562-RT to describe the 3 views of the right knee. Using the RT/LT
modifiers respectively indicated to the payer of the procedures performed on each knee.
Example: If doctor marks on encounter 73560- LT and 73565 would be acceptable.
If 73562-RT is marked with 73565, 73565 would be changed to 73560-LT and 73562-RT would be “up coded” to 73564. 73564-LT marked with 73565, only the 73565 would be changed to 73560-RT.
If 73565 is done only for comparison purposes then only the x-rays pertaining to the symptomatic knee would be billed and again-“up coded” to reflect the additional view.