By Daniel J. Nagle, MD
ASSH Practice Division Director
Chair, ASSH Coding and Physician Reimbursement Committee
New Codes for 2008
The 2008 CPT® nomenclature is now official and the AMA will allow me to give you a preview of the new codes.
The big news is that we were able to rid our fracture nomenclature of the phrase “with or without internal or external fixation.” This nomenclature was created in the early 90’s by Brad Henley, MD, currently a member of the AMA CPT® (Current Procedural Terminology) Editorial Panel and member of the Orthopedic Trauma Association. Dr. Henley was quite clear in his original presentation to the AMA CPT® Editorial Panel that if both internal and external fixation were used to treat a fracture, the CPT® code for external fixation (20960) and the code describing the internal fixation of the fracture should be used. The Global Service Guide for Hand Surgery clearly states this and the AAOS Global Services Guide also agrees with this.
Unfortunately, some third party payers, including CMS, preferred to interpret “or” in the code descriptor as meaning “and.” The AAOS and ASSH, as well other musculoskeletal surgery societies, rewrote the fracture codes last year eliminating the vagueness of the word “or.” The new codes include the terminology “Open treatment of XYZ fracture, includes internal fixation, when performed.” “When performed” replaces “with or without.” The introduction to the Musculoskeletal System Section of the CPT® manual indicates that external fixation codes are to be used only when external fixation is not already listed as part of the basic procedure – this applies to all of the revised codes that eliminate the phrase “or external fixation” for CPT® 2008.
You will recall we asked you to complete many RUC (Relative Value Scale Update Committee) surveys to help us develop recommendations for relative values for the new/revised codes. Thanks to your efforts, we had good data for our codes and in many instances were able to show the codes were undervalued. These codes were reviewed under the umbrella of the Physician Fee Schedule 5-Year Review such that family budget neutrality will not apply. This allowed us to get increases for some codes without decreasing the values of our existing codes.
I have included the new fracture codes in this Coding Corner (included below as a PDF). I will include the new code relative values before year end. I cannot include them here as the official values accepted by CMS will not be available until November when they are published in the Federal Register.
Pay for Performance
I know you are all concerned about Pay for Performance and PQRI. I have asked Mike Keith, MD, Chair of the ASSH Evidenced Based Practice Committee, to write a “white paper” on this subject to help us all understand what is going on with this rapidly evolving process.
Correct Coding Initiative Edits
Nick Vedder, MD (one of our local hosts in Seattle) has discovered that some payers and CMS are bundling skin grafts with the work of harvesting and insetting a myocutaneous or myofascial flap (15756.) The denials are based on a recent CCI (Correct Coding Initiative) edit that, for unknown reasons, began bundling the skin graft codes with 15756. This is indeed strange given that 15756 was accepted by the CPT® Editorial Panel and valued by the AMA RUC ten years ago. You will note that the service descriptor (see below) for this code does NOT include harvesting or applying skin grafts. The relative value for this code never included the physician work associated with the harvesting and application of a skin graft. A letter outlining the history of this code and its valuation along with our rationale for removing the erroneous edit has been sent to Dr. Niles Rosen of Correct Coding Solutions (the government contractor handling the CCI process). I will keep you posted on the outcome of our effort. In the meantime, I would suggest you continue coding for any skin grafts performed in association with 15756 and that you append the -59 modifier to the skin graft codes.
Free muscle or myocutaneous flap with microvascular anastomosis
“The latissimus dorsi muscle without skin is harvested through a long posterolateral incision. If a muscle flap with skin is required, a skin paddle is outlined over the latissimus dorsi and the dissection is carried down to the latissimus dorsi muscle, taking care to attach the skin paddle to the latissimus dorsi fascia. Meticulous dissection is carried out to free the latissimus from the surrounding soft tissues and underlying muscles and chest wall. Once the pedicle is identified, microdissection to the vascular pedicle is completed. The flap is then harvested, transferred to the recipient bed, and loosely sewn in place. The operating microscope is then used to perform the microanastomosis of one artery and one or two veins using 9-0 or 10-0 suture. Attention to detail is critical at this juncture of the procedure, as even micro-injury to the vessels will lead to failure of the flap. The insetting of the flap is then meticulously completed. A drain is placed beneath the flap. Meticulous hemostasis of the donor site is achieved and the wound closed in layers of drains. A bulky dressing is applied to the recipient site and reinforced with plaster splint.”
Dan Nagle, MD
ASSH Practice Division Director
2008 Fracture Codes.pdf