see coding, page 35 - · pdf filereport bilateral procedures, report [27215–27218] with...

30 AAOSNow March2010 ManagingYourPractice ManagingYourPractice March2010 AAOSNow 31

HaveyoureceivedadenialfromMedicare,statingthatCategoryICurrentProcedureTerminology(CPT)codes27215–27218arein-valid?Ifso,you’renotalone.

In2009,theAmericanMedicalAssociation(AMA)madechangestotheCPTdescriptorsforthosecodesandtoitscodingguidelinestoclarifythateachofthesurgicalprocedureswasforthetreatmentofaunilateralpelvicinjury.Inthepresenceofbilateralpelvicinjuries,thesesurgicaltreatmentscouldbebilledbilaterally.

TheCentersforMedicareandMedicaidServices(CMS),however,inits2009MedicarePhysicianFeeSchedule,didnotagreewiththeAMACPTchanges.Thisdeci-sionhasandiscontinuingtocauseconfusionaboutcodingpelvicfrac-turesanddislocations.

Initsopinion,Medicarestatedthatthepelvisisasingleana-tomic(ie,unilateral)structure.Asaresult,Medicaredoesnotallowbilateralbilling.Instead,Medicarecreatedfournew“G”codes(tem-porarynationalcodes)toreportandbereimbursedforpelvicsurgi-calprocedures,whichwouldbeconsideredasunilateralonly.

The2010AMACPTManualincludesthefollowinginstructionwithcodes27215–27218:“Toreportbilateralprocedures,report[27215–27218]withmodifier50.”Althoughthisiscorrectcodingforthird-partypayors,itisnotcor-rectcodingforMedicare.Because

Medicaredoesnotrecognizethebilateralmodifierfortheseservices,correctlycodingthesefourproce-duresforMedicarebeneficiariesrequiresthatyouusetheGcodes.

Here’stherule:Tocodepelvicfracturescorrectly,useCPTCat-egoryIcodeswhenbillingnon-

MedicarepayorsanduseMedi-care’stemporarynationalGcodeswhenbillingMedicare.

Understanding the shiftTable1showshowthefive-digitCategoryICPTcodesparalleltheassociatedMedicareGcodes.NotethatMedicareaddedthetermsunilateralorbilateraltotheGcodes,thusinvalidatingCPTcodes27215–27218asvalidcodes.

ItisimportanttounderstandhowtoreadtheMedicarefeeschedulesothatyoucanidentifywhenacodeisinvalid.Theulti-matetoolforfast,easy,andaccu-ratecodingandcross-referencingisOrthopaedicCodeX,whichnotonlyshowsthecodestatusofeachcodebutalsoenablesyoutonavi-gate,translate,andintegrateallsixcriticalcodingdatabases.

InFig.1,theCodeStatusforCPTcodes27215-27218showsthattheyareinvalidcodesforMedicare,andanyclaimssubmit-tedtoMedicareusingthesecodeswillbedenied.

CodesurgicaltreatmentofpelviscorrectlyByMaryLeGrand,RN,MA,CCS-P,CPC

Medicare decision to treat pelvis as unilateral structure creates confusion

Table 1: Parallel coding for pelvic fractures

CPT CPT Description 2010 Medicare Medicare Description Medicare RVUs Code RVUs for Temporary for Unilateral or Unilateral G Code Bilateral Procedure Procedure

27215 Opentreatmentofiliacspine(s), 18.45 G0412 Opentreatmentofiliacspine(s), 18.45 tuberosityavulsion,oriliacwing tuberosityavulsion,oriliacwing fracture(s),unilateral,forpelvicbone fractures(s),unilateralorbilateral,for fracturepatternsthatdonotdisrupt pelvicbonefracturepatternswhichdo thepelvicring,includesinternalfixation, notdisruptthepelvicring(includes whenperformed internalfixation,whenperformed)

27216 Percutaneousskeletalfixationof 27.21 G0413 Percutaneousskeletalfixationof 27.21 posteriorpelvicbonefractureand/or posteriorpelvicbonefractureand/or dislocation,forfracturepatternsthat dislocation,forfracturepatternswhich disruptthepelvicring,unilateral disruptthepelvicring,unilateralor (includesipsilateralilium,sacroiliac bilateral(includesilium,sacroiliac jointand/orsacrum) jointand/orsacrum)

27217 Opentreatmentofanteriorpelvicbone 25.72 G0414 Opentreatmentofanteriorpelvicbone 25.72 fractureand/ordislocationforfracture fractureand/ordislocationforfracture patternsthatdisruptthepelvicring, patternswhichdisruptthepelvicring, unilateral,includesinternalfixation, unilateralorbilateral,includesinternal whenperformed(includespubic fixationwhenperformed(includespubic symphysisand/oripsilateral symphysisand/orsuperior/inferiorrami) superior/inferiorrami)

27218 Opentreatmentofposteriorpelvicbone 35.37 G0415 Opentreatmentofposteriorpelvicbone 35.37 fractureand/ordislocation,forfracture fractureand/ordislocation,forfracture patternsthatdisruptthepelvicring, patternswhichdisruptthepelvicring, unilateral,includesinternalfixation, unilateralorbilateral,includesinternal whenperformed(includesipsilateral fixation,whenperformed(includesilium, ilium,sacroiliacjointand/orsacrum) sacroiliacjointand/orsacrum)

See CODING, page 35

Fig. 1Ascanbeseenonthisscreenshotofthe2010OrthopaedicCodeX,the“I”inthestatuscolumnmeansthattheCPTcodeisinvalidandwillbedeniedbyMedicare.

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