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Orthopaedic Coding Q&A: Diagnostic Arthroscopy and Meniscectomy; Removal and Reinsertion of Cages

Posted in Practice Management Solutions | Feb 2015 | Comments (0)

Tags: Editor's Choiceorthopaedic surgerymedical practice management tipsarthroscopic surgerycodingkneespine

The Coding Coaches address orthopaedic coding questions and hot-button coding issues. In this round: Diagnostic Arthroscopy and Meniscectomy and Removal/Reinsertion of Cages.

Question: Can I report a right meniscectomy and left diagnostic knee arthroscopy during the same session?

Answer: Yes; CPT code 29881 (meniscectomy) and CPT code 29870 (diagnostic arthroscopy) are reportable during the same operative session when they are independently performed on different knees. Use of modifiers may be payor-dependent. According to CPT rules, you would report 29881 and 29870-59. Some payors may want the RT/LT modifiers alone; some may want the RT/LT and the 59. In 2015, the "X" modifier for separate structure might be required.

Question: Our surgeon documented a revision of an interbody fusion and wants to report 22849 for the removal of a cage and placement of a new cage. Is this an acceptable use of the re-insertion code?

Answer: Great question, and one that is commonly asked in our orthopaedic coding courses! CPT code 22849 is not appropriate to report in this scenario. If the surgeon's documentation supports a level of complexity over and above for the revision interbody fusion, the possibility exists of appending modifier 22 for the increased procedural service and complexity.

For previous coding questions and answers, click here.

The Orthopaedic Coding Coaches are Mary LeGrand, RN, MA, CCS-P, CPC and Margaret Maley, RN, BSN, MS of Karen Zupko and Associates (KZA), a practice management consulting and training firm working for and with physicians since 1985. Visit the KZA site at to learn more.


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