Suggested Billing Codes

Many insurance providers have a coverage policy and coding guidelines for CARTICEL^®.  We recommend you verify with the insurance provider specific coverage requirements and which code is most appropriate in order to facilitate payment prior to submitting a claim. 

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.

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.

Physician Documentation Tips

Cartilage Biopsy (Stage 1)

Since authorization is often dependent upon documentation from the harvesting of the healthy articular cartilage, and since insurance company case managers often rely on measurable objective data, please include the following information in the operative report from the Arthroscopy with Cartilage Biopsy:

• 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)

Modifiers:
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.