Although orthopedic societies have pushed to make shoulder surgery coding more akin to coding for other joint procedures, many Medicare guidelines still consider the shoulder as a one-compartment joint. In other words, while there’s been some movement toward the two-compartment viewpoint, many coding guidelines for shoulder surgery procedures haven’t entirely caught up.
That’s why—whether you’re coding extensive versus limited debridement or reporting 29826 based on questionable documentation—shoulder surgery coding is no easy task, even for experienced coders, orthopedics coding expert Margie S. Vaught explains in ProfEdOnDemand’s 2019 Coding Updates Virtual Boot Camp for Orthopedics (which includes co-presenter Lynn Anderanin).
Here are three key tips to help improve the accuracy of your shoulder surgery coding.
Know the Proper Time to Code Extensive Debridement
In 2017, the Centers for Medicare & Medicaid Services (CMS) drastically changed the coding rules for extensive debridement (CPT ® code 29823), making the coding conventions more similar to those of coding for the knee, according to the American Academy/Association of Orthopaedic Surgeons (AAOS).
You now have three situations in which you can bill 29823 when the extensive debridement portion of the procedure is performed in a separate area of the shoulder joint:
- Arthroscopic distal clavicle resection (29824);
- Arthroscopic RC repair (29827); and
- Biceps tenodesis (29828).
Example: The operative report states that the surgeon performed arthroscopic subacromial decompression at the same time as extensive debridement, shaving the undersurface of the distal clavicle and debriding the chondral surfaces. In this case, the primary code would be 29823 for extensive debridement, and the secondary code would be the acromioplasty (29826), AAOS illustrated.
Note: Acromioplasty is an add-on code, so you can never report it as the primary code and you do not need modifier 51 or 59.
Allow Anatomy to Guide SLAP Lesion Coding
Another problem: If you don’t understand the lesion anatomy, coding for SLAP tears can be confusing.
There are four classifications of SLAP tears, according to eORIF LLC:
- Type I – Degenerative superior labrum with fraying along the free margin (treatment is debridement);
- Type II – Labrum and biceps origin are detached from the labrum (treatment is arthroscopic SLAP repair if physical therapy fails);
- Type III – Bucket-handle labral tear with firmly attached labrum and biceps origin (treatment is arthroscopic biceps tenotomy with or without biceps tenodesis if physical therapy fails); and
- Type IV – Bucket-handle tear of superior labrum with extension into the biceps tendon with biceps displacement (treatment is biceps tenotomy with or without biceps tenodesis if physical therapy fails).
How to code: For Types II and IV, you should code 29807 for repair of the lesions, and look for details on the anchor or suture repair in the operative note, AAOS recommended. Code Types I and III using 29822 for arthroscopic biceps tenotomy. Also, code 29823 only if the surgeon performed more extensive debridement during the surgery.
Tread Carefully When Using Modifier 59
Yet another issue that you’ll face when coding shoulder surgery is your use of modifier 59 to identify a distinct procedural service. CMS has been cracking down on use of this modifier and has been scrutinizing shoulder surgery coding in particular.
You should be especially wary of using modifier 59 when the surgeon performs more than one procedure during the same operative session and on the same shoulder, according to a CMS factsheet on modifier 59 guidelines.
Example: You are coding 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair in Column 1 and 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial in Column 2.
In this case, you should not use modifier 59. If the surgeon performed both procedures on the same shoulder during the same operative session, do not code 29820 and do not append modifier 59. If the surgeon performed the procedures on different shoulders, use modifiers RT and LT – not modifier 59.
“The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites,” CMS stressed.
Bottom line: Bundling, modifier usage, and the growing number of CPT® codes for shoulder procedures are all crucial factors that greatly impact your coding, Vaught says. Make sure your orthopedic surgeons are aware of the important documentation issues – and ensure that you’re selecting the right codes – so you can maximize your reimbursement and prevent denials.
