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 Coding Corner February 2005

By Daniel J. Nagle, MD
Chair, ASSH CPT/RUC Committee

64718 Update

AdminiStar Federal has responded to our request to correct the erroneous bundling of 64718 (Neuroplasty and/or transposition; ulnar nerve at elbow) with 24305 (Tendon lengthening, upper arm or elbow, each tendon). The following is AdminiStar’s response.

“This edit was implemented on January 1, 1999. The source for the edit was the American Academy of Orthopaedic Surgeons' (AAOS) book entitled Complete Global Service Data for Orthopaedic Surgery. The text indicated that the global service package for CPT code 24305 included neuroplasty and specifically mentioned CPT code 64718. The 2004 edition of the book continues to state that the global service package for CPT code 24305 includes "neuroplasty for surgical exposure" although it no longer specifically identifies CPT code 64718 as an example.”

I have asked Gary Frykman, MD, our representative on the AAOS Global Services Committee, to encourage the AAOS to correct their Global Services book to more accurately reflect current practice.  While I believe it is reasonable to use this code pair for non-medicare patients when performing anterior submuscular transposition of the ulnar nerve combined with a Z-lengthening of the flexor pronator tendon, I suspect third party payers will use the CCI edit to deny payment.  Medicare rules prohibit this code pair at this time.

First CMC Suspension Arthroplasty

This topic has been discussed on several occasions in the Coding Corner. However, LRTI continues to be a source of headaches for many of our billing offices. Recently the AMA Coding Assistant published an extensive article on this very subject.  The article reflects the thinking of the ASSH CPT/RUC Committee.  This is significant since many third party payers rely on the AMA Coding Assistant to evaluate the appropriateness of provider coding.  I believe the information in the AMA Coding Assistant, Vol.  15:1, January 2005, will add significant weight to your appeals. (Subscription information can be obtained by calling 800-621-8335 or visiting the AMA website.)

Vascularized Bone Grafts: Update

The May 2001 Coding Corner touched on this issue. At that time it was suggested that 25440, Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) be combined with 15740 Flap; neurovascular pedicle. The recommended code combination was: 15750 + 25440-51.  Since 15750 has the higher RVU it is considered the primary code, while 25440 would be listed with the multiple procedure modifier -51.

The ASSH CPT/RUC Committee reviewed this coding issue at its September 2005 meeting.  It was the consensus of the Committee that a more reasonable method of coding for repair of a scaphoid nonunion using a vascularized bone graft would be:

25440  Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation)
25430-51 Insertion of vascular pedicle into carpal bone (eg, Hori procedure)

Rationale:  The code 25440 includes the open reduction and internal fixation of the scaphoid, the harvesting of the bone graft and a radial styloidectomy. The “flap” described by 15750 Flap; neurovascular pedicle, in this case would be the bone graft. Therefore, the combination of 15750 + 25440 describes harvesting the bone graft twice. The only aspect of a vascularized radial bone graft not considered in 25440 is the work associated with the dissection of the vascular pedicle.  The physician work associated with the dissection of the vascular pedicle is very close to the work described by code 25430 Insertion of vascular pedicle into carpal bone (eg, Hori procedure).  Admittedly 25430 includes the drilling of a hole in the recipient bone, however, that aspect of the procedure accounts for only a small portion of the total intraoperative time.  If one looks at the RBRVS data on the combination 25440 +25430 one notes that the combined intraoperative time for these two procedures is 190 minutes (3 hours 10 minutes).  The total facility RVU, when taking into consideration the -51 modifier, would be 30.34.  That is equal to the RVU for a total nephrectomy.

Code   RVW Total     Facility RVU   Intra Time
25440      10.42            21.42            90
25430       9.25            17.84            100

Other News
The American College of Radiology is currently lobbying Congress to restrict Medicare payment for the reading of X-rays to “qualified radiologists.”  Needless to say this has not been well received by many specialties.  A coalition of specialty societies (including the AAOS and ASSH through the AAOS) has been formed to block any such legislation. Drs. Levin and Rao outline the rationale for such legislation in Turf Wars in Radiology: Possible Remedies for Self-Referral That Could Be Taken by Federal or State Governments and Payers, David C. Levin, MD, Vijay M. Rao, MD J Am Coll Radiol 2004;1:806-810.  I have heard rumors that Congress has let it be known that it is not interested in this issue as it feels this should be handled by the department of Health and Human Services.

The American College of Surgeons recently asked specialty societies to respond to a Government Accounting Office (GAO) request to update the list of procedures that can be safely performed in an ambulatory surgical center (ASC). The members of the ASSH CPT/RUC Committee provided comments to the ACS which were forwarded to the GAO.  The ASSH recommendations are available in the document attached below.

The American College of Surgeons also asked the ASSH to update its Physician as Assistant at Surgery database.  Again the members of the ASSH CPT/RUC Committee rallied and provided the ACS a list of hand surgery procedures that require a physician assistant.  The final ACS product, integrating our recommendations into a “surgical consensus report,” is not yet available.  This is a document used by CMS (Centers for Medicare and Medicaid Services) and could be a useful resource for hand surgeons. The 2002 version is available from the ACS:

Code well!


ASSH ASC List Recommendations.pdf

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