CPT code and description
29881 - Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed average fee amount - $540 - $600
29871 - ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE
29873 - ARTHROSCOPY KNEE LATERAL RELEASE
29874 - ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY
29875 - ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX
29876 - ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS - Average fee payment $740
29882 - ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL
29883 - ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL
29884 - ARTHROSCOPY KNEE W/LYSIS ADHESIONS W/WO MANJ SPX
Is the value of CPT code 29875 included in the value of code 29881 billed on the disputed date? Does the documentation support a separate service* Is the requestor entitled to reimbursement?
28 Texas Administrative Code §134.203(b)(1) “For coding, billing, reporting, and reimbursement of professional medical services, Texas workers' compensation system participants shall apply the following: Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules.”
According to the explanation of benefits, the respondent denied reimbursement for code 29875-LT-59 based upon reason code “X901.”
On the disputed date of service, the requestor billed CPT codes 29881-LT and 29875-LT-59.
Per CCI edits, CPT code 29875 is a component of CPT code 29881; however, a modifier is allowed to ifferentiate the service. A review of the requestor’s billing finds that the requestor appended modifier “59-Distinct Procedural Service” to CPT code 29875.
Modifier 59 is defined as “Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
However, when another already established modifier is appropriate it should be used rather than modifier 59.
Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”The respondent maintains the denial of payment for code 29875 based upon “Per NCCI, 29875 is incidental to 29881…Modifier not supported as same knee.”
The National Correct Coding Initiative Manual defines “separate procedure” as “The narrative for many HCPCS/CPT codes includes a parenthetical statement that the procedure represents a "separate procedure". The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed. A “separate procedure” should not be reported when performed along with another procedure in an anatomically related region through the same skin incision or orifice, or surgical approach.”
The Division finds that because code 29875 has the parenthetical statement “separate procedure” the CCI policyapplies. Both procedures code 29881 and 29875 were performed on the same anatomically related region (knee); therefore, 29875 cannot be reported with 29881 and the use of modifier 59 is not supported. As a result, reimbursement is not recommended.
For the reasons stated above, the Division finds that the requestor has established that additional reimbursement is not due. As a result, the amount ordered is $0.00.
Is knee arthroscopy typically covered by health insurance plans*
Yes, knee arthroscopy is usually covered by health insurance. Always check with your insurer to make sure a procedure is covered before seeking treatment. Your insurer may require pre-certification prior to agreeing to cover your knee arthroscopy.
You should always ask and then confirm that your provider is going to obtain precertification for your knee arthroscopy before you receive treatment.
If your provider does not obtain pre-certification prior to your knee arthroscopy, you will need to call the health plan and request pre-certification yourself. Insurers may deny payment of the claim if you have not obtained pre-certification.
Is knee arthroscopy typically covered by Medicare or Medicaid plans*
Yes, knee arthroscopy is covered under Medicare and Medicaid. Your provider may need to establish medical necessity or pre-certification before you receive treatment.
What kind of out-of-pocket costs should I expect to pay*
Your out of pocket costs will depend on the type of insurance that you have. You maybe responsible for copays, deductibles or coinsurance amounts. In order to determine your out of pocket costs, always review your co-pay amounts, current deductible balance and current co-insurance obligation before seeking treatment. If you have questions about your benefit plan or out of pocket costs, talk to your insurance company.
Remember, if you have a Health Savings Account (HSA) or Health Reimbursement Account (HRA) you can apply those funds to any deductible, co-insurance or other out of pocket costs.
Anthem Central Region bundles 29870, 29871, 29875 and 29884 as incidental with 29881; bundles 29870-50, 29871-50, 29875-50 and 29884-50 as incidental with 29881-50; bundles 29870-LT, 29871- LT, 29875-LT and 29884-LT as incidental with 29881-LT and bundles 29870-RT, 29871-RT, 29875- RT and 29884-RT as incidental with 29881-RT. Based on the Complete Global Service Data for
Orthopaedic Surgery, codes 29870, 29871, 29875 and 29884 are listed as procedures that included in CPT 29881. Based on the National Correct Coding Initiative Edits, codes 29870, 29871, 29875 and 29884 are listed as component codes to code 29881. Therefore, if 29870, 29871, 29875 and/or 29884 is submitted with 29881—only 29881 reimburses; if 29870-50, 29871-50, 29875-50 and/or 29884-50 is submitted with 29881-50—only 29881-50 reimburses; if 29870-LT, 29871-LT, 29875-LT and/or 29884-LT is submitted with 29881-LT—only 29881-LT reimburses and if 29870-RT, 29871-RT, 29875-RT and/or 29884-RT is submitted with 29881-RT—only 29881-RT reimburses.
Anthem Central Region does not bundle 29870-59, 29871-59, 29875-59 and 29884-59 with 29881; does not bundle and does not bundle 29870-LT, 29871-LT, 29875-LT and 29884-LT with 29881-RT. If 29870, 29871, 29875 or 29884 is performed on one knee and 29881 is performed on the opposite knee, either append modifier 59 to 29870, 29871, 29875 or 29884; or append the appropriate LT or RT modifier on 29870, 29871, 29875 or 29884 and the opposite LT/RT side modifier on 29881. Therefore, if 29870-59, 29871-59, 29875-59 and/or 29884-59 is submitted with 29881—both services reimburse separately or if 29870-LT, 29871-LT, 29875-LT and/or 29884-LT is submitted with 29881-RT—both services reimburse separately.
Anthem Central Region bundles 29874 as incidental with 29881. Based on National Correct Coding Initiative Edits, code 29874 is listed as a component code to code 29881. If a loose body is less than 5 mm and is removed from the same incision, it is included in 29881. If the loose body is greater than 5mm or a separate incision is required to remove this loose body, append modifier 59 on 29874 and both services reimburse separately. If 29874 is performed on one knee and 29881 is performed on the
opposite knee, append the appropriate LT/RT modifier to 29874 and the opposite LT/RT modifier to 29881 and both reimburse. Therefore, if 29874 is submitted with 29881—only 29881 reimburses. If 29874-59 is submitted with 29881—both services reimburse separately or if 29874-LT is submitted with 29881-RT—both services reimburse separately.
Anthem Central Region does not bundle 29879 or 29882 with 29881. Based on the Complete Global Service Data for Orthopaedic Surgery, codes 29879 or 29882 are not listed as being included in the performance of 29881. Based on the National Correct Coding Initiative Edits, codes 29879 and 29882 are not listed as being component to code 29881. Therefore, if 29879 or 29882 is submitted with 29881—both services reimburse separately
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
* ISSUE IN DISPUTE: Provider is seeking reimbursement for Procedure codes: 29870-59-RT, 29881-RT, and 29875-59-RT.
* The Provider billed the disputed codes as well as Procedure 20610-59-RT for date of service 12/19/2014.
* Per a review of the NCCI edits, the following code pairs exist;
* 29870:20610 Misuse of column two code with column one code
* 29875:20610 Misuse of column two code with column one code
* 29875:29870 Procedure “Separate Procedure” definition
* 29881:20610 Misuse of column two code with column one code
* 29881:29870 Procedure “Separate Procedure” definition
* 29881:29875 More Extensive Procedure
* The Claims Administrator denied Procedure 29881 with the following explanation: Documentation does not support the level of service billed.
* The Operative Report substantiated the billed procedure 29881. A Right knee arthroscopic procedure was performed. Operative Report, “The medial compartment revealed an intact meniscus and articular surface. The lateral compartment revealed a complex tearing in the anterior and midlateral portions. This was debrided with a shaver.”
* Reimbursement is recommended for Procedure 29881.
* Procedure 29875: Some procedures can be performed at varying levels of complexity. The HCPCS/Procedure codes corresponding to more extensive procedures always include the HCPCS/Procedure codes corresponding to less complex procedures. HCPCS/Procedure code 29881 is a more extensive procedure that includes HCPCS/Procedure code29875. Accordingly, only the more extensive procedure, HCPCS/Procedure code 29881 should be reported. HCPCS/Procedure code 29875 is bundled into HCPCS/Procedure code 29881. The operative report did not document a separate anatomical site or encounter to substantiate separate reimbursement for Procedure 29875.
* Reimbursement is not recommended for Procedure 29875.
RESPONDENT’S POSITION SUMMARY
Respondent’s Position Summary: “The billed CPT of 29876 flags a NCCI Edit when billed with CPT 29888 and 29880. The operative record shows that CPT 29876-59 was performed in the patellofemoral joint, and in the lateral and medial compartments. CPT 29876-59 as billed is not supported in the documentation because the synovectomy was performed in the same compartments as the meniscectomy (medial and lateral) and same site as the ACE; therefore Modifier 59 is not supported. CPT 20610 flags a NCCI Edit when billed with CPT 29880, 29876, and 29888. The operative record shows that a steroid anesthetic injection was given through the medial portal. CPT 20610-59 as billed is not supported in the documentation because the injection is given through the same medial portal as the procedures performed during the same operative session. Modifier 59 is therefore not supported.”
According to the explanation of benefits, the respondent denied reimbursement for code 29876-59-LT based upon the service was not documented. The respondent contends that payment is not due because “The billed CPT of 29876 flags a NCCI Edit when billed with CPT 29888 and 29880. The operative record shows that CPT 29876-59 was performed in the patellofemoral joint, and in the lateral and medial compartments. CPT 29876-59 as billed is not supported in the documentation because the synovectomy was performed in the same compartments as the meniscectomy (medial and lateral) and same site as the ACE; therefore Modifier59 is not supported.” 28 Texas Administrative Code §134.203(a)(5) states “Medicare payment policies” when used in this section, shall mean reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies as set forth in the Centers for Medicare and Medicaid Services (CMS) payment policies specific to Medicare.” On the disputed date of service the requestor billed CPT codes 29888-LT, 29880-59-LT, 29876-59-LT and 20610-59-LT.
28 Texas Administrative Code §134.203(b)(1) states “For coding, billing, reporting, and reimbursement of professional medical services, Texas workers' compensation system participants shall apply the following: (1) Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules.” Per CCI edits, CPT code 29876 is a component of code 29888 and 29880; however, a modifier is allowed to differentiate the service. The requestor appended modifier 59-Distinct Procedural Service” to code 29876 to differentiate it from 29888 and 29880. Modifier “59” is defined as “Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day.
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