# shoulder manipulation with arthrogram?



## BFAITHFUL (Oct 30, 2011)

doc performed a shoulder arthrogram, with an articular joint injection and manipulation under anesthesia for adhesive capsulitis.  He wants to bill 23350, 20610 & 23700.

I know all of these can't be billed altogether but at the same time i'm not sure which ones to bill?  I'm thinking just 23700 because the reason why patient came in was for adhesive capsulitis, so i think the joint injection is bundled and as far as the arthrogram, this is not properly documented/supported anyway.

HISTORY AND INDICATIONS:
Marcela is a 49 year old female who was injured in a motor vehicle pedestrian accident on February 15, 2011.  She was struck by a motor vehicle and suffered a left shoulder injury with a shoulder dislocation.  This was reduced in the emergency room; however, she developed an adhesive capsulitis in the left shoulder with significant limitation of motion despite substantial amount of physical therapy.  Because of her lack of response to physical therapy, a plan was to perform an arthrogram with followup intraarticular steroid injection to give her some pain relief and then manipulate her under sedation and the local.

OPERATIVE PROCEDURE:
The patient was brought into the OR.  She was placed in a radiolucent table with her arm by her side.  We then prepped and draped in the usual strict sterile manner.  We oblique the C arm to get a true AP view of the left shoulder.  After prepping and draping, we then injected local in the skin overlying the shoulder joint.  We then slowly threaded a 22-gauge spinal needle into the shoulder under fluoroscopic guidance.  We confirmed placement with arthrography.  The arthrogram also revealed that there is a lack of normal inferior recess or pouch consistent with adhesive capsulitis.  Once we confirmed successful intraarticular placement in the arthrogram we then injected 80 mg of Depo-Medrol and 3 cc of 0.5% Marcaine into the joint.  I saw the dye layered out and it did not track outside the joint into the subacromial space.  There was no sign of cuff tear.  We then withdrew the needle and then I manipulated the left shoulder raising it overhead and also passively externally rotating her and a nice abductor position.  We felt adhesions were let go and she had better overhead elevation and external rotation upon completion of manipulation.  Pre Manipulation in 90 degree flexion position showing about 45 and 50 degrees of external rotation.  Upon completion, she was near 90 degrees.  She returned to the recovery room in stable condition.


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## sauka (Oct 30, 2011)

BFAITHFUL said:


> doc performed a shoulder arthrogram, with an articular joint injection and manipulation under anesthesia for adhesive capsulitis.  He wants to bill 23350, 20610 & 23700.
> 
> I know all of these can't be billed altogether but at the same time i'm not sure which ones to bill?  I'm thinking just 23700 because the reason why patient came in was for adhesive capsulitis, so i think the joint injection is bundled and as far as the arthrogram, this is not properly documented/supported anyway.
> 
> ...



I am going with the Doctors codes
sauka


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## RonMcK3 (Oct 30, 2011)

sauka,

I'm just starting. What facts lead you to agree with the Dr's coding?

Thanks,


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## sauka (Oct 31, 2011)

RonMcK3 said:


> sauka,
> 
> I'm just starting. What facts lead you to agree with the Dr's coding?
> 
> Thanks,



these r the codes in the CPT manual am also studying to take my CPC EXAM next month but i have coded b4 in Accounts payable.\\

Txs


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## RonMcK3 (Oct 31, 2011)

sauka,

Thanks for replying. My concern was whether any combination of these codes runs afoul of NCCI. After downloading the NCCI Edits MS Excel files, I find that for MCR, 20610 needs a modifier whenever it's used with 23350 or 23700. 

BFaithful, where is the radiology code (probably 73040)? Is it being separately billed by a radiologist? There's no mention of one in the op report.

So, is the coding the following?

23350-LT
20610-51-LT
23700-51-LT

Thanks,


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## sauka (Oct 31, 2011)

RonMcK3 said:


> sauka,
> 
> Thanks for replying. My concern was whether any combination of these codes runs afoul of NCCI. After downloading the NCCI Edits MS Excel files, I find that for MCR, 20610 needs a modifier whenever it's used with 23350 or 23700.
> 
> ...


23350-50, 20610-50, 23700
when i checked in my cpt this is what i found, since i have not used the NCCI, but its not showing the LT and the modifier is 50, if there is no mention of one in the op report probably the radiologist is coding since radiology codes are separate codes.

Tell me when u get it right
txs

sauka


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## BFAITHFUL (Nov 1, 2011)

See that's the problem with the radiology part.... I don't see adequate documentation for the arthrogram (23350), AND you can't do an articular joint injection (20610) anyway along with the arthrogram.  Also I know the NCCI edits doesn't show that it's bundled.....sometimes even though NCCI doesn't show two codes being bundled doesn't mean you can bill for both.  


For Example see the following from NCCI Manual:

When it is necessary to perform skeletal/joint
manipulation under anesthesia to assess range of motion, reduce a
fracture or for any other purpose during another procedure in an
anatomically related area, the corresponding manipulation code
(e.g., CPT codes 22505, *23700*, 27275, 27570, 27860) is not
separately reportable


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## RonMcK3 (Nov 1, 2011)

BFaithful,

What's the effective date of your NCCI Edits manual?

In the Mutually Unlikely Edit (MUE) file I find the following entries: 

Col 1 Col 2 Col 3 *=In existence prior to 1996 
----- ----- - 
............v.Col 4 Effective Date 
............v....v.....Col 5 Deletion Date *=no data
............v....v.....v.Col 6 Modifier 0=not allowed,
............v....v.....v.v.....1=allowed, 9=not applicable"
----- ----- - -------- - - -------------------------
23350 20610 . 20110101 * 1 (1 = modifier allowed)
23700 20610 . 20110101 * 1

So, as of 1/1/2011, NCCI says we can use 20610 with 23350 and/or 23700 in the same case if we have the appropriate modifiers. If your NCCI Edit book is current (2011), does it cite a NCD or LCD as authority for denying use of these in a single session? Or, have you had these denied this year in other cases?

As to your observation:



			
				BFaithful said:
			
		

> See that's the problem with the radiology part.... I don't see adequate documentation for the arthrogram (23350), ... <snip>


 
Aren't the following highlighted parts of the OR sufficient to support an appropriate radiology code? If not, what's missing? (I ask because I'm busy learning.) 



			
				BFaithful said:
			
		

> The patient was brought into the OR. She was placed in a radiolucent table with her arm by her side. We then prepped and draped in the usual strict sterile manner. We oblique the C arm to get a true AP view of the left shoulder. After prepping and draping, we then injected local in the skin overlying the shoulder joint. We then slowly threaded a 22-gauge spinal needle into the shoulder under fluoroscopic guidance. We confirmed placement with arthrography. The arthrogram also revealed that there is a lack of normal inferior recess or pouch consistent with adhesive capsulitis. Once we confirmed successful intraarticular placement in the arthrogram we then injected 80 mg of Depo-Medrol and 3 cc of 0.5% Marcaine into the joint. I saw the dye layered out and it did not track outside the joint into the subacromial space. There was no sign of cuff tear. We then withdrew the needle and then I manipulated the left shoulder raising it overhead and also passively externally rotating her and a nice abductor position. We felt adhesions were let go and she had better overhead elevation and external rotation upon completion of manipulation. Pre Manipulation in 90 degree flexion position showing about 45 and 50 degrees of external rotation. Upon completion, she was near 90 degrees. She returned to the recovery room in stable condition.


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## BFAITHFUL (Nov 2, 2011)

the arthrogram was performed as a diagnostic test but it was just to confirm what physician already knew patient had which was "adhesive capsulitis" see "Indication" section.  

As far as the NCCI edits..... a modifier is allowed which we know would be modifier 59 which means "Distinct procedure" but what would be "distinct & separate" about billing the joint injection code, 20610 separately from 23700?


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## sharon.strong@lpnt.net (Jun 13, 2013)

I am very interested in this thread, billing 20610 with 23700, and the correct modifier.  Is anyone being reviewed for using these codes together??


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