What’s new in pediatric orthopaedic billing and coding?

Introduction

The medical billing and coding system in the United States is a complex process that is determined from interactions between several stakeholders. Evaluation and Management (E&M) and Current Procedural Terminology (CPT) codes are developed and maintained by the American Medical Association (AMA). The AMA’s recommendations for current and new CPT codes, their relative value units (RVUs), and revisions to CPT codes are usually (but not always) accepted by the Centers for Medicare and Medicaid Services, which is the federal agency most directly involved in our healthcare system. Each year, new codes are created, unused codes are discontinued, the descriptors of codes may be changed, or the RVU values of codes may be changed. The following are known recent changes for E&M and CPT codes that are relevant to pediatric orthopedic surgeons.

Pulling pins in an office setting

Former guidance from the American Academy of Orthopaedic Surgeons (AAOS) was that pulling pins in the office was included during a global period [1]. However, after reassessing the issue, AAOS now recommends that if the removal of internal fixation is not specified as included in the original fixation procedure, then the removal of pins is reportable as a subsequent procedure.

An AMA publication stated in 2007 that it was appropriate to report implant removal in the office following closed treatment of a mandibular fracture since it was not considered an inclusive component of the original procedure [2]. The interpretation of this guidance is that it is analogous to pin removal in the office following orthopedic procedures. If removal of internal fixation is not specified as included in the original fixation procedure, then it is reportable as a subsequent procedure using the code for removal of a superficial implant, 20670 [3]. To ensure appropriate reimbursement, best practice would be to state in the operative report that the patient will return to the office for staged pin removal. Some payers may require the −58 modifier for a staged or related procedure during a global period.

Preparation and insertion of drug-delivery devices

The AMA approved codes for the fabrication of drug-delivery devices and included them in the CPT manual in 2022 [5]. These codes are appropriate when a drug (usually an antibiotic) is mixed with medical cement and shaped into structures (beads, rods, etc.) that are then placed into wounds prior to closure. Code 20700 is used when the device is placed subfascially in the wound. 20702 is used when the device is placed intramedullary. 20704 is used when the device is placed intra-articular.

The language in the CPT manual lists multiple codes that are appropriate to use in conjunction with 20700, 20702, or 20704 in parentheticals:

+20700 Manual preparation and insertion of the drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure).

(Use 20700 in conjunction with 11010, 11011, 11012, 11043, 11044, 11046, 11047, 20240, 20245, 20250, 20251, 21010, 21025, 21026, 21501, 21502, 21510, 21627, 21630, 22010, 22015, 23030, 23031, 23035, 23040, 23044, 23170, 23172, 23174, 23180, 23182, 23184, 23334, 23335, 23930, 23931, 23935, 24000, 24134, 24136, 24138, 24140, 24147, 24160, 25031, 25035, 25040, 25145, 25150, 25151, 26070, 26230, 26235, 26236, 26990, 26991, 26992, 27030, 27070, 27071, 27090, 27301, 27303, 27310, 27360, 27603, 27604, 27610, 27640, 27641, 28001, 28002, 28003, 28020, 28120, 28122).

(Do not report 20700 in conjunction with any services that include placement of a spacer [eg, 11981, 27091, 27488]).

+20702 Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure).

(Use 20702 in conjunction with 20680, 20690, 20692, 20694, 20802, 20805, 20838, 21510, 23035, 23170, 23180, 23184, 23515, 23615, 23935, 24134, 24138, 24140, 24147, 24430, 24516, 25035, 25145, 25150, 25151, 25400, 25515, 25525, 25526, 25545, 25574, 25575, 27245, 27259, 27360, 27470, 27506, 27640, 27720).

(Do not report 20702 in conjunction with 11981, 27091, 27488).

+20704 Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure).

(Use 20704 in conjunction with 22864, 22865, 23040, 23044, 23334, 23335, 23473, 23474, 24000, 24160, 24370, 24371, 25040, 25250, 25251, 25449, 26070, 26990, 27030, 27090, 27132, 27134, 27137, 27138, 27301, 27310, 27487, 27603, 27610, 27703, 28020).

(Do not report 20704 in conjunction with 11981, 27091, 27488).

However, the preamble to the section for these codes notes: “They may be used with any open procedure code except those that include the placement of a “spacer” (eg, 27091, 27488).” Because the language in the preamble takes precedence over the language in the code descriptors, it should be possible to use them in conjunction will all CPT codes except those specifically used for spacers, though institutions and payers may have different interpretations of this discrepancy.

While typically used in the setting of active infection, it is also possible that drug-delivery devices might be indicated as prophylaxis against infection. For example, if cement beads mixed with antibiotic powder are placed adjacent to spine implants during a posterior spinal fusion, the use of 20700 could be acceptable. The preamble language in the CPT manual also notes: “The add-on codes may be used when infection is present, suspected, or anticipated during the surgery.” Note that these codes cannot be used when antibiotic powder is used alone. They require the fabrication of a cement device to deliver the medication.

Medical decision making for inpatient services

Beginning in 2021, the AMA introduced a new format to guide billing for outpatient office-based E&M services [4]. They created a new option, distinct from the previous 1995 and 1997 rules that relied on documentation of multiple bullet points for the history, physical, and medical decision-making. The new option is dependent on medical decision-making (MDM) alone. For each visit, the physician determines the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management. These three factors determine the level of service (LOS) based on MDM.

Beginning in 2023, it has been acceptable to apply this same methodology to determine the LOS for inpatient services [6]. Inpatient services include consultations, initial hospital visits, observation care services, subsequent inpatient or observation services, and admission and discharge services performed on the same day. Alternatively, time can be used to determine the LOS in these settings instead of MDM. Note that time required to complete the service now encompasses all time spent on the service by the same practitioner on the same day, including face-to-face time with the patient and family, documentation, review of records, and any coordination of care. Hospital or observation discharge services remain dependent on time alone.

Preoperative optimization

At the AMA’s CPT Editorial Meeting in the fall of 2022, the committee clarified that existing codes for principal care management services can be used for preoperative optimization of complex patients [7]. While likely intended for older patients with multiple medical comorbidities undergoing surgery, these codes could be applied to complex pediatric patients, especially those with congenital syndromes or neuromuscular conditions. Codes 99424 and 99425 indicate the first 30 minutes and each additional 30 minutes of time spent on preoperative optimization by a practitioner. Codes 99426 and 99427 indicate the first 30 minutes and each additional 30 minutes spent on preoperative optimization by clinical staff. To qualify for preoptimization, the patient must have a condition defined as chronic (lasting more than 3 months), the provider or staff must document development, monitoring, or revision of a disease-specific care plan, there must be frequent adjustments in the medication regimen and/or the management of the condition must be unusually complex due to comorbidities, and there must be ongoing communication and care coordination between relevant practitioners furnishing care.

Split-shared rules

A split-shared visit occurs when two practitioners see a patient together at a single encounter. A common example might be when an advanced practice provider (APP) and a physician share the duties required to perform a visit in an outpatient clinic. Since neither practitioner can take credit for doing all the work required to complete the encounter, billing using split-shared rules applies. This is different from the situation where an APP performs all the work to complete an encounter, bills under their own name, and is merely supervised by a physician. It is also different from the situation where a physician is present in the same location and the APP performs the encounter and bills under the physician’s name using “incident-to” rules. In a split-shared visit, both the APP and the physician see the patient and perform some of the work.

Currently, for split-shard visits, the physician may bill for the entire visit using an appropriate E&M code if the documentation suggests that the physician performed the majority of the history OR the majority of the physical exam, OR the majority of the medical decision-making. Beginning in 2025, there is a proposal to simplify this metric to document who utilized the most time to complete the encounter or who did the majority of the medical decision-making. Keep in mind that, as above, time can include face-to-face time with a patient, time required to document the encounter, time required to review records, and time required to coordinate care. Only time required on the day of the encounter may be used to determine the level of service and documentation for choosing a level of service. There may be several ways to document time spent caring for a patient, including time stamps from the electronic medical record or auditing of keystrokes used to create progress notes. The simplest way to document the time spent providing a service may simply be to state the total minutes for all aspects of the encounter in the note itself.

When using MDM as the metric to determine the LOS for split-shared visits, the practitioners should determine who does the majority of approving the care plan for the problems addressed and who takes the majority of the responsibility related to the management of risks. If data are used to select the MDM Level, only the person who performs an independent interpretation or discussion of the management or test interpretation may use the data category to determine the LOS. The LOS will still be determined from the highest level in 2 out of the 3 categories (problems addressed, data, and management risk).

Spinal growing rods

Correct billing and coding for the insertion of spinal growing rods remains controversial. Informal polling of pediatric spine surgeons suggests that most use some combination of standard spinal deformity fusion and instrumentation codes since growing rod insertion typically involves a limited proximal fusion, a limited distal fusion, and instrumentation spanning these two locations. The AMA addressed this issue in the December 2022 issue of CPT Assistant [8]. The AMA stated in this article that no current CPT code accurately describes the work involved with the insertion of growing rods and that the unlisted spine code (22899) should be used. Unlisted CPT codes do not have any associated RVU values. Reimbursement is typically determined on an individual basis by providing the payer with a description of the work and suggesting similar codes that can be used as references for the unlisted procedure. Additionally, for institutions where physician reimbursement is determined by RVU values, it would be incumbent on the physician to negotiate their reimbursement rate for an unlisted code.

The AMA also determined that lengthening of magnetic growing rods in a clinic setting should also be coded as an unlisted spine procedure (22899). If a separate evaluation of the patient is done during the office visit where magnetic rod lengthening is performed outside of the global period for growing rod insertion, then it is appropriate to use an E&M code with an appropriate level of service in addition to the unlisted spine code for the rod lengthening. Typically, a modifier −25 would be added to the E&M code to indicate a separately identifiable service on the same day that will have a new 10-day global period.

Vertebral body tethering (VBT) codes

Prior to 2024, the VBT codes were 0656T (tethering up to 7 segments), and 0657T (tethering for 8 segments or more). Both codes were “Category III” codes, which are temporary codes that are used to record and track newer technologies. Similar to unlisted codes, Category III codes have no assigned RVU values to guide reimbursement, so the professional fees must be negotiated with payers on an individual basis. New Category I codes for thoracic VBT with assigned RVU values were implemented as of January 1, 2024. There are listed under the Spinal Instrumentation in the CPT manual [10].

22836 Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments.

(For anterior lumbar or thoracolumbar vertebral body tethering, up to 7 vertebral segments, use 0656T).

22837 8 or more vertebral segments

(Do not report 22836, 22837 in conjunction with 22845, 22846, 22847, 32601).

(For anterior lumbar or thoracolumbar vertebral body tethering, 8 or more vertebral segments, use 0657T).

22838 Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed.

(Do not report 22838 in conjunction with 22849, 22855, 32601).

Please note that the definition of a “segment” from the CPT Manual is the bony components of a vertebral body [4], [5], [6], [10]. Segments do not include the mobile disks between vertebrae. So, one segment should be counted for each vertebra included in the VBT procedure. For example, a VBT from T5 to T12 includes 8 vertebrae and would be counted as 8 segments. Also, note that these new codes are applied to thoracic VBT only. The current language for the Category III codes changed to state “lumbar/thoracolumbar” VBT, as appropriate literature to merit Category I codes was only available for thoracic VBT procedures.

0656T Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments.

0657T 8 or more vertebral segments

(Do not report 0656T, 0657T in conjunction with 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22845, 22846, 22847).

(For vertebral body tethering of the thoracic spine, see 22836, 22837).

0790T Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed.

(For revision, replacement, or removal of thoracic vertebral body tethering, use 22838).

Wound closure and open fractures

Wounds associated with open fractures are automatically considered “complex.” Several years ago, the language in the introductory section for wound repair in the AMA’s CPT manual were changed to state: “Complex repair does not include… debridement of an open fracture or open dislocation” [9]. Therefore, codes 13120, 13121, and 13122 for wound repair of the extremities can be used in addition to the codes for debridement of an open fracture (11010, 11011, and 11012). 13120 indicates repair of a complex wound measuring 1.1 cm to 2.5 cm. 13120 indicates repair of a wound measuring 2.6 cm to 7.5 cm, and 13122 is an add-on code for each additional 5.0 cm or less. A wound repair code would not be appropriate in the setting of an open fracture for a wound 1.0 cm or less. The wound repair codes require primary wound closure using sutures, staples, tissue adhesives, or adhesive strips. They would not be appropriate when temporizing measures are used and wounds are partially or completely left open, as in the setting of wound VAC or rubber band techniques.

Summary

Changes to CPT codes occur annually through a process managed by the AMA. Remaining up to date on current coding practices helps ensure appropriate reimbursement and compliance with CPT standards. Please reach out to your POSNA representative for the AAOS CCRC or members of the POSNA Practice Management Committee with any questions related to pediatric orthopedic billing and coding.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.