Physician documentation tips
Cartilage Biopsy (Stage 1)
Since authorization is dependent upon the documentation recorded at the biopsy harvest, and insurance company case managers often rely on measurable objective data, it is important to include the following information collected at the biopsy harvest in the patient's operative report:
- Prior treatments and current symptoms (unless noted in H&P)
- Number of defects
- Defect location(s)
- Defect size (after debridement)
- Grade of defect(s)
- Health and stability of rest of the knee
- Absence of Osteoarthritis (CARTICEL is not indicated for use in patients with OA)
- Clearly state medical necessity for and intent to treat with CARTICEL.
- Clearly state that the patient was educated about CARTICEL as a treatment option
- If the patient has worker’s compensation, establish causation and indicate how correcting the defect will impact return to work status
- Use the word “implant” not “transplant”
Post-operative visit notes:
- Clearly state the intent to treat the patient with ACI
CARTICEL Implantation (Stage 2)
The CPT Code alone is not sufficient to describe the details of a surgical procedure, providers may wish to provide additional information in the claims submission. The AMA has developed Modifiers which are designed to allow providers to more precisely communicate the extent of the professional services performed. Some modifiers that may be used in conjunction with 27412 include:
22: Unusual Procedural Services - When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier “22” to the usual procedure number. A report may also be appropriate.
Example: This modifier may be used to describe procedure when multiple (more than one) or large uncontained defects are being treated.
51: Multiple Procedures - When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier “51” to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes.
Example: This modifier may be used to describe a condition when multiple procedures are performed to treat a co-existing condition or morbidity concurrent to the implantation, i.e. Meniscal allograft reconstruction; proximal tibial or distal femoral osteotomy or tibial tubercle osteotomy.
*Note: All CPT codes, above, are taken from AMA CPT, 2005, Introduction. CPT codes, descriptions, and material only are copyright 2004 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.