“We are having difficulty with a denial when combining CPT 28320 and CPT 20680. CPT 20680 is being rejected as unbundling. According to CCI edits, CPT 28320 is a Column 1 code and CPT 20680 is a Column 2 code and they are allowed. The surgeon removed hardware from a prior surgery performed by a different surgeon not associated with the practice then repaired a non-union and applied new fixation. Is the removal of prior hardware actually included in CPT code 28320? If not, what modifier should be used if it is the same incision/surgical site as the non-union repair?”
CPT code 28320 is defined as: Repair, nonunion or malunion; tarsal bones
CPT code 20680 is defined as: Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate)
When the CCI edits are accessed, CPT code 20680 is a Column 2 code to CPT code 28320. This means that on the same date of service, at the same anatomical site, if both procedures are being performed, CPT code 20680 is not reimbursable. That is why CPT code 20680 was rejected in the above post. When both CPT codes are billed, this is an example of UNBUNDLING.
Let’s be real about this. The patient had a non-union that resulted from a prior surgery that was performed by a surgeon that is no longer associated with the practice. It doesn’t matter who the prior, original surgeon was. The procedure to repair the non-union was performed by a surgeon that is currently in the practice. In order to repair the non-union, the original hardware had to be removed (CPT code 20680) and as part of the non-union repair (CPT code 28320), new hardware needed to be placed at the non-union site. There is an example per Medicare of “two bites of the apple.” Unfortunately, you only get one bite. That is why CPT codes 28320 and 20680 are bundled.
Is there a modifier to append to so that both CPT codes can be reimbursed? Well, theoretically, you can append the 59 modifier to CPT code 20680 which designates that CPT code 20680 is a Distinct Procedural Service. But, is it really? No.
You can bill CPT code 28320 as the only CPT code for the posted scenario and perhaps append the 22 modifier to designate: INCREASED PROCEDURAL SERVICES. You would need to submit the claim hard copy with a copy of the operative report to demonstrate the “increased procedural service.” Under the best of circumstances, the use of the 22 modifier is difficult to justify. In this situation, is what was performed really an “increased procedural service?” Well, you can’t put new hardware in without taking the old hardware out first. Unfortunately, this will never past the litmus test. It is still “two bites of the apple.”
This is my opinion.
Dr. Michael G. Warshaw
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