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Medical Coding News Archives

Coding Arthroscopic Shoulder Surgery

September 26, 2017:

Although arthroscopic surgeries are common, they can be confusing to report because of the array of surgical interventions that can be performed through the scope. Adding to the confusion are the numerous guidelines on how to report multiple procedures performed during the same surgical encounter.

According to the Centers for Medicare and Medicaid Services (CMS), the shoulder is considered a single anatomic structure. Note that, with just a few exceptions, a National Correct Coding Initiative (CCI) procedure-to-procedure edit code pair consisting of two codes describing two shoulder arthroscopy procedures should never be bypassed with a CCI-associated modifier when the two procedures are performed on the ipsilateral shoulder. This type of edit may be bypassed with a CCI-associated modifier only if the two procedures are performed on contralateral (left and right) shoulders.

The endoscopic procedure involves four small incisions where the instruments needed to perform the procedure are placed. Fluid is injected to help inflate the area for better visualization and mobility throughout the procedure. A small arthroscope is placed into one of the incisions to provide video of the procedure details.

The surgeon might then use the scope to survey the area to learn the exact extent of the injury or disease process. Fluid continues to be injected into the area to keep it open as well as to better control the bleeding within the area. When the procedure is performed for diagnostic reasons only or when a synovial biopsy is performed, report CPT code 29805. Note that this code describes a separate procedure. Also remember that diagnostic endoscopic procedures are included in surgical endoscopies and should not be reported in addition to surgical arthroscopic procedures. During the diagnostic procedure, the clinician may identify other conditions that can be performed during the surgical encounter. These services are identified by other CPT codes. The correct code selected depends on the type of repair performed.

For example, the physician indicates that the patient underwent a diagnostic arthroscopy of the shoulder. However, the documentation indicates that the physician identified the corticoid process. The anterior capsule was visualized through a small transverse incision of the subscapularis tendon, which was tagged for identification and removed from its attachment on the capsule. The physician assessed the quality and laxity of the capsule and explored the joint for damage to the labrum or glenoid. The joint was irrigated to remove any loose bodies. The capsule was advanced superiorly and attached to the labrum with sutures. The appropriate amount of slack was taken up to provide stability within the joint. Once the capsule was reattached, the subscapularis tendon was reapproximated (but not tightened) and repaired. In this instance, code 29806 is reported; because the surgical arthroscopy includes the diagnostic arthroscopy, no other code is appropriate.

The following guidelines should be kept in mind when reporting shoulder arthroscopic procedures:

  • As indicated above, surgical arthroscopy includes diagnostic arthroscopy, which is not separately reportable. If a diagnostic arthroscopy leads to a surgical arthroscopy at the same patient encounter, only the surgical arthroscopy may be reported.
  • If an arthroscopy is performed as a “scout” procedure to assess the surgical field or extent of disease, it is not separately reportable. However, when during a diagnostic arthroscopy (29805) the provider makes the decision to perform an open procedure, the diagnostic arthroscopy may be separately reportable. Modifier 58 should be appended to the open surgical procedure code. The medical record must indicate the medical necessity for the diagnostic arthroscopy.
  • When an arthroscopic procedure is converted to an open procedure, only the open procedure may be reported.
  • Medicare and most other payers include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than other procedures at the same surgical session.
  • Codes 29824 (arthroscopic claviculectomy), 29827 (arthroscopic repair of the rotator cuff), and 29828 (biceps tenodesis) may be reported separately with CPT code 29823 for extensive debridement if the debridement was performed in a different area of the same shoulder.

The surgeon should document the diagnoses, a brief history of the patient, the step-by-step details of the procedure, any assistants involved and what they helped with, as well as the disease or injury state as visualized during the operation. Depending on the diagnosis, the surgeon should indicate laterality, the type of injury, the extent of the injury, as well as the specific location of the area involved. Below is a sample list of possible diagnosis codes that could be associated with a shoulder surgery.

  • C40.01 Malignant neoplasm of scapula and long bones of right upper limb
  • M66.111 Rupture of synovium, right shoulder
  • M71.011 Abscess of bursa, right shoulder
  • M71.312 Other bursal cyst, left shoulder
  • M75.01 Adhesive capsulitis of right shoulder
  • M75.111 Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic
  • M75.42 Impingement syndrome of left shoulder
  • M80.011K Age-related osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion
  • M84.312P Stress fracture, left shoulder, subsequent encounter for fracture with malunion
  • M84.812 Other disorders of continuity of bone, left shoulder
  • M85.512 Aneurysmal bone cyst, left shoulder

The note should thoroughly describe adhesions, additional injuries, degenerative bone, and other conditions that add time and complexity to the procedure.

Because correct code assignment depends on the documentation, it should be recorded immediately following the procedure. Besides the federal, state, or facility regulations that may define a time frame within which to complete documentation, postponing writing the note might cause facts to be missed because memories become less acute over time. Documentation should include details of the conditions being treated, particularly those identified during the surgical encounter, affecting the surgical intervention provided, and supporting the medical necessity of the service.

This article is one of more than a thousand included in Optum360’s Specialty Articles available as an add-on to a subscription to our online coding tools. The articles rely on information from experts in various specialties, are fully searchable, and include sources. For more information, go to https://www.optum360coding.com/Product/36102/.

CPT only © American Medical Association. All rights reserved.


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