Understand the Shoulder Joint Structure Concepts to Ace Surgical Coding

If you make these modifier 59 blunders, you face a mountain of denials

Making costly coding mistakes when reporting shoulder surgical procedures is, sadly, rather easy. After all, you have a whole host of complex coding rules to follow – not to mention the major coding and documentation changes that have come down the pike for 2018.

From the documentation you need to support extensive versus limited debridement, to when you can report CPT code 29826, you have a lot of minutiae to sort through, according to orthopedic coding expert Margie Scalley Vaught in her audioconference, “Shoulder Surgical Procedure Coding and Documentation Changes.” Start with the basics and move toward the more complex coding rules, so you can code shoulder procedures with confidence.

Identify Different Shoulder Arthroscopy Procedures

Pay attention: Arthroscopy is a surgical procedure in which the surgeon inserts a small fiberoptic camera into the joint through a small incision, explained AIM Specialty Health. Arthroscopy allows the surgeon to visualize the joint and also to treat a variety of conditions. You may see arthroscopy procedures such as:

  • Rotator Cuff Repair
    • Acute full thickness tear
    • Chronic or degenerative full thickness tear
    • Partial thickness tear
    • Revision rotator cuff repair
  • Labral Tear
    • Superior Labral Anterior-Posterior (SLAP) tear
  • Subacromial Impingement Syndrome (without Rotator Cuff Tear)
  • Arthroscopic Capsular Release for Adhesive Capsulitis
  • Manipulation under Anesthesia (MUA) for Adhesive Capsulitis
  • Capsulorrhaphy (Bankart Procedure)
  • Partial Claviculectomy
  • Mumford Procedure
  • Tendinopathy of the Long Head of the Biceps

 

Stay Current on Coding Revisions

The traditional coding rule for the shoulder is to consider the joint as one compartment, but orthopedic societies have promoted a two-compartment (intra- and extra-articular) viewpoint, according to the American Academy of Orthopaedic Surgeons (AAOS).

Break it down: “Intra-articular structures include the labrum, the long head of the biceps, a Bankart lesion, and the humeral and glenoid articular surfaces,” AAOS stated. “Extra-articular structures include the rotator cuff (RC), the distal clavicle, and the subacromial space.”

In response, CMS has made a few changes to the coding rules, such as the significant revision to the extensive debridement code (29823). CMS separated this code into three codes, so you can report extensive debridement performed in a separate area of the shoulder joint, similar to coding for the knee. These codes include:

  • 29824 – Arthroscopic distal clavicle resection;
  • 29827 – Arthroscopic RC repair; and
  • 29828 – Biceps tenodesis.

 

Hidden trap: Don’t confuse these coding changes with reporting the limited debridement code 29822, which is included with the other, more extensive arthroscopic procedure codes, AAOS warned. These changes apply to the extensive debridement code only.

Likewise: This same guidance governs synovectomy codes in both the shoulder and the knee, AAOS said. CPT code 29820 for partial synovectomy is inclusive to more extensive procedures, while you should use code 29821 for complete synovectomy only when the underlying diagnosis is pathologic synovium, such as is found in rheumatoid arthritis or pigmented villonodular synovitis.

Don’t Make These Modifier 59 Mistakes

One of the biggest mistakes that coders make when reporting shoulder arthroscopy procedures is misuse of modifier 59. And the recent changes to the coding rules don’t help.

Rule of thumb: If the documentation describes arthroscopic treatment of structures in adjoining areas of the same shoulder, this constitutes treatment of a single anatomic site, according to a Centers for Medicare & Medicaid Services (CMS) MLN Matters article on the proper use of modifier 59.

Example: Your Column 1 code is 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair. Your Column 2 code is 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial.

In this case, you should not report CPT code 29820 with modifier 59 if the surgeon performed both procedures on the same shoulder during the same operative session, CMS stated. The shoulder joint is a single anatomic structure. But if the surgeon performed the procedures on different shoulders, you should use modifiers RT and LT, not modifier 59.

Bottom line: Coding shoulder surgical procedures, including arthroscopy, is no easy task, and you need to stay up on bundling and modifier rules, as well as the many changes in 2018 for CPT codes and CCI guidelines. Vaught can walk you through these changes and much more, ensuring that you master shoulder surgery coding and documentation compliance so you can nab deserved reimbursement and avoid claims denials.

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