Billing codes
The following coverage, coding, and payment information is provided for informational purposes only and should not be construed as legal advice. The information has been compiled from various resources and is subject to change. Providers should exercise independent clinical judgment when selecting codes and submitting claims to reflect accurately the services rendered to individual patients. Third-party payment for medical products and services is affected by numerous factors. Providers are encouraged to contact third-party payers for specific information on their coverage, coding, and payment policies.
Biopsy Procedures Codes
Typical ICD-9CM codes
- 717.9 Unspecified internal derangement – knee
- 719.96 Unspecified disorder of joint – knee
- 732.7 Osteochondritis Dissecans
- 733.90 Disorder of bone & cartilage, unspecified
- 733.92 Chondromalacia (excludes patella)
- 836.0 Tear of medial cartilage or meniscus – knee
- 836.1 Tear of lateral cartilage or meniscus – knee
- 836.2 Other tear of cartilage or meniscus – knee
Typical CPT* codes used for biopsy
- 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
Typical concomitant CPT* codes
- 29874 Arthroscopy, knee, for removal of loose body or foreign body (eg. osteochondritis dissecans fragmentation, chondral fragmentation
- 29877 Arthroscopy, knee, Debridement/shaving of articular cartilage (chondroplasty)
- 99070 Supplies and materials (except spectacles) provided by physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies or materials provided)
The preceding codes are commonly used to identify the biopsy procedure. If the biopsy was performed as a secondary procedure, remember to use the primary arthroscopic surgical procedure CPT code. Consequently, the insurance provider may down-code any incremental charges associated with taking the biopsy. Incremental charges submitted by the surgeon may be disallowed, and the biopsy may be paid for under a global fee that includes the primary procedure.
CPT codes should be indicated in box 24D on the CMS - 1500 form.
Autologous Chondrocyte Implantation Codes
Typical ICD-9CM codes
- 717.9 Unspecified internal derangement - knee
- 719.96 Unspecified disorder of joint - knee
- 732.7 Osteochondritis Dissecans
- 733.90 Disorder of bone & cartilage, unspecified
- 733.92 Chondromalacia (excludes patella)
- 836.0 Tear of medial cartilage or meniscus - knee
- 836.1 Tear of lateral cartilage or meniscus – knee
- 836.2 Other tear of cartilage or meniscus - knee
CPT Code* :
The American Medical Association (AMA) has issued a unique and permanent Category I CPT Code for autologous chondrocyte implantation (ACI), effective January 1, 2005. The exact terminology is a follows:
27412: Autologous Chondrocyte Implantation, Knee
CPT codes are widely accepted by third party insurers. Please use the above code for CARTICEL implantation.
CPT Modifiers
Physicians may bill modifiers to indicate that a procedure performed has been altered by some specific circumstances, but not changed in its definition or code. Some modifiers that may be appropriate for billing for CARTICEL implantation include:
Modifier 51
When multiple procedures are performed on the same day or at the same operative session, providers should identify the secondary, additional or lesser procedure(s) by adding Modifier 51 to the secondary procedure code(s).
Modifier 22
Providers use Modifier 22 to indicate an unusual procedure was provided greater than that usually required. Additional reimbursement beyond the usual may be made if the payer agrees the procedure involved exceptional circumstances. This modifier may be used for patients with multiple defects, and will trigger manual review of the claim.
Typical concomitant CPT* codes
27418 Anterior tibial tubercleplasty (eg. Maquet type procedure)
- 29868 Meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
- 27457 Osteotomy after epiphyseal closure
- 27428 Intra-articular (open) (ACL repair / reconstruction)
Important notes for physician offices
- Reimbursement will depend upon the contract with the insurer. The physician may want to consult with the insurer’s contracting representative to determine how the contract may affect reimbursement.
- CPT Codes should be indicated in box 24D on the CMS – 1500 form.
- Please note that a listed Category I CPT Code precludes the need for the CMS – 1500 form. In most cases the claim may be filed electronically.