Shoulder Arthroscopic Surgery Coding Made Easy
For providers coding arthroscopic surgery, certain knowledge of the shoulder’s ball-and-socket anatomy can ease up the complexities of coding. The Centers for Medicare & Medicaid Services (CMS) considers shoulder joint as a single anatomic region, whereas, American Academy of Orthopedic Surgeons (AAOS) considers the glenohumeral joint, the acromioclavicular (AC) joint, and the subacromial bursa as separate anatomic areas. This difference creates challenges for providers coding arthroscopic surgery. It is important to first understand the shoulder joint.
Anatomy of Shoulder
The shoulder is a complex joint made of three bones: upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). Shoulder joint is capable of more motion than any other joint in your body.
Ball and socket: Shoulder joint is also called Ball and Socket joint as the head of the upper arm bone fits into a rounded socket in the shoulder blade. The socket is called the glenoid that is covered by articular cartilage, which enables a smooth, frictionless surface that helps the bones glide easily across each other. The glenoid is ringed by strong fibrous cartilage called the labrum that forms a gasket around the socket to add stability.
Shoulder capsule. The joint is surrounded by ligaments that form a capsule that holds the joint together. The capsule is lined by a thin membrane called the synovium, which produces synovial fluid that lubricates the shoulder joint.
Rotator cuff. The shoulder capsule is surrounded by four tendons to help keep your arm bone centered in your shoulder socket. This thick tendon material is called the rotator cuff. The cuff covers the head of the humerus and attaches it to your shoulder blade.
Bursa. In between the rotator cuff and the bone on top of your shoulder (acromion) there is a lubricating sac called a bursa, which helps the rotator cuff tendons glide smoothly when you move your arm.
How to Code Shoulder Arthroscopic Procedures:
There has been a lot of confusion surrounding coding of shoulder procedures, especially arthroscopic procedures. In the past few years, a number of new arthroscopic shoulder CPT codes have been added. However, some aspects of the CPT coding system itself remain confusing.
Here are some tips on how to code shoulder procedures.
If you have to code a right, arthroscopic rotatorcuff repair with a distal claviculectomy, acromioplasty, and debridement of the labrum. A subacromial decompression is performed, with 1 cm removed from the distal clavicle.
You might want to report:
- 29827-RT Arthroscopy, shoulder, surgical; with rotator cuff repair-Right side,
- 29824-RT Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure),
- +29826-RT Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure), and
- 29822-RT-59 Arthroscopy, shoulder, surgical; debridement, limited-Distinct procedural service.
The issue with this coding is that 29822 bundles into 29827 and 29824, per National Correct Coding Initiative edits; and because this is the same shoulder, it’s inappropriate to use a modifier to bypass the bundling edit.
To determine whether the charges support 29824, first answer this 3 question: was the service performed on the shoulder arthroscopically, has it been performed on the distal clavicle, and was approximately 1 cm removed? If your answer is yes to all the questions, you may report 29824.
However, if the answer is no, a more appropriate code may exist. For e.g. if the provider is addressing the AC joint, creating a 1 cm space at the AC joint, he is referring to the distal end of the clavicle and the acromion. This results in insufficient documentation to support either 29824 or 29826.
Subacromial Decompression with Partial Acromioplasty
Code 29826 involves both a subacromial decompression and a partial acromioplasty.
In case if acromioplasty is not performed, report only a debridement. This add-on code requires a primary procedure. Remember, when coding the acromioplasty, don’t forget to determine if the acromion is flat, curved, or hooked. Answer this question: was the creation of the 1 cm space in the AC joint due to a distal claviculectomy, acromioplasty, or both?
- If one acromioplasty is performed, report a debridement (29822 or 29823).
- If acromioplasty is performed with distal claviculectomy, it’s possible the two procedures created the 1 cm space; you may report 29824 or 29826, but not both.
Rotator Cuff Surgery
Open rotator cuff repair is confusing because three codes can be used:
- 23410 (Repair of musculotendinous cuff, acute)
- 23412 (Repair of musculotendinous cuff, chronic)
- 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty])
- 29827 (arthroscopic rotator cuff repair)
- For arthroscopic rotator cuff reconstruction, check with your payer, (e.g., 29999 Unlisted procedure, arthroscopy).
Note: As there are no standardized definitions to differentiate acute from chronic rotator cuff surgery, often the difference is the size of the lesion (i.e., how many tendons are involved or whether the lesion is less than 1 cm, 1 cm to 3 cm, 3 cm to 5 cm or more than 5 cm), as well as the amount of retraction and scarring, not how long ago the tear occurred.
SLAP lesions are coded according to their types.
- TYPE I: Repair (debridement) of a type I SLAP lesion is always coded as 29822 (Arthroscopic debridement, limited).
- TYPE II and IV: Repairs of types II and IV SLAP lesions are coded 29807 (Repair SLAP lesion) because an actual repair is performed.
- Type III SLAP lesions are bucket-handle tears and can be either debrided or repaired; use 29822 or 29807, whichever is appropriate.
Note: Reporting code 29806 (Arthroscopy, shoulder, surgical, capsulorrhaphy) for repair of a SLAP lesion is never appropriate unless there is a capsular defect in an area different than the SLAP.
Synovectomy and Debridement
CPT doesn’t distinguish synovectomy and debridement; however, there are codes for both. Generally, debridement is reserved for situations in which articular cartilage is debrided, whereas, synovectomy codes is used when only soft tissue is removed. A partial synovectomy (29820) or limited debridement (29822) would consist of work done in just a portion of the shoulder. To support a complete synovectomy (29821) or extensive debridement (29823), the documentation should support work in BOTH the front and back of the shoulder.
There are ongoing issues with shoulder arthroscopy procedures and CCI guidelines are starting to limit the number of codes you will be able to report. AudioEducator is conducting an audio session on 2016 Shoulder Procedure Coding, where expert speaker Margie Scalley Vaught will review the changes, CCI guidelines and Bundling Issues. For more information,
Article Source: AAPC