Arthroscopy is a surgical procedure that allows the direct visualization of the interior joint space. In addition to providing visualization, arthroscopy enables the process of joint cleansing through the use of lavage or irrigation. Lavage alone may involve either large or small volume saline irrigation of the knee by arthroscopy. Although generally performed to reduce pain and improve function, current practice does not recognize the benefit of lavage alone for the reduction of mechanical symptoms. Arthroscopy also permits the removal of any loose bodies from the interior joint space, a procedure termed debridement. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9).
In June, 2004 CMS issued a national coverage determination (NCD) for non-covered arthroscopic procedures for patients with osteoarthritis. This NCD specified that medical necessity decisions for coverage of debridement procedures in patients without severe osteoarthritis of the knee who presented with symptoms in addition to pain were at the discretion of the Medicare contractor (carrier or intermediary). This article reiterates non-coverage instructions in CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9 and provides coding and billing guidelines for arthroscopic lavage and debridement procedures. All language quoted from Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout this article.
Indications:
Not applicable
Limitation: CMS does not consider the following procedures to be reasonable or necessary in the treatment of the osteoarthritic knee and is considered non-covered by the Medicare program:
- Arthroscopic lavage used alone for the osteoarthritic knee; or
- Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,
- Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis
Patients without severe osteoarthritis of the knee who present with symptoms other than pain alone; i.e., (1) mechanical symptoms that include, but are not limited to, locking, snapping, or popping (2) limb and knee joint alignment, and (3) less severe and/or early degenerative arthritis, remain at local contractor discretion. Medicare contractors may require submission of one or all of the following documents to define the patient’s knee condition:
- Operative notes,
- Reports of standing x-rays, or,
- Arthroscopy results.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services):An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.
Specific coding information for this policy
The physician/provider performing the procedure is responsible for identifying those patients for whom Medicare does not consider the procedure “reasonable or necessary.”
Report CPT code 29999 (Unlisted procedure, arthroscopy) for arthroscopic lavage of the knee for treatment of osteoarthritis and/or arthroscopic debridement and lavage for patients with severe osteoarthritis.
Report CPT code 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chrondroplasty]) for arthroscopic debridement with presentation of knee pain only, or arthroscopic debridement without lavage for patients with severe osteoarthritis.
Report HCPCS code G0289 for arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee.
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
