# Unlisted procedure codes



## dyoungberg (Mar 23, 2012)

I work in an ASC and recently our doctor performed the following procedure:

PROCEDURE: 
1. RIGHT SHOULDER DIAGNOSTIC ARTHROSCOPY 
2. RIGHT SHOULDER ARTHROSCOPIC SUBSCAPULARIS AND SUPRASPINATUS ROTATOR CUFF REPAIRS 
3. RIGHT SHOULDER ARTHROSCOPIC CORACOPLASTY 
4. RIGHT SHOULDER ARTHROSCOPIC ACROMIOPLASTY 
5. RIGHT SHOULDER ARTHROSCOPIC MUMFORD 
6. RIGHT SHOULDER ARTHROSCOPIC CHONDROPLASTY 

ANESTHESIA:       GENERAL 

IMPLANTS:            MITEK 5.5 MM HELIX-BR SUTURE ANCHORS X FOUR 

INTRAOPERATIVE FINDINGS:  
1.   Complete tear of the subscapularis tendon with retraction from the lesser tuberosity.
2.   Biceps auto tenotomy. 
3.   Chondral flap tear to the posterior aspect of the glenoid with intact cartilage on the remainder of the glenoid
      and humeral head. 
4.   Anterior, inferior, posterior labrums intact. 
5.   Superior labrum with degenerative fraying. 
6.   Axillary recess free and clear of any loose bodies. 
7.   Posterior and posterior mid rotator cuff intact. 
8.   Anterior rotator cuff with full thickness crescent-shaped tear with delamination, approximately 17.0 mm's in 
      length. 
9.   Hook type II acromion with large anterior inferior spur. 
10. AC joint stenosis, hypertrophy, and degeneration. 

INDICATIONS FOR PROCEDURE:   69 year old female with a long history of right shoulder pain, unresponsive to non operative treatments. The patient was evaluated in the clinic with an MRI that showed a rotator cuff tear. The risks and benefits of surgical management were discussed with her and she was given the opportunity to ask questions regarding her treatment plan. When all questions were answered to her satisfaction, she elected to proceed with surgery and signed informed consent. 

PROCEDURE IN DETAIL:   The patient was greeted in the preoperative holding area where the right shoulder was correctly identified and initialed as the surgical site. She was then administered an interscalene block by anesthesia for postoperative pain management. Next, she was brought back to the operating room for her procedure where she was placed supine on the OR table and appropriate cardiopulmonary monitoring devices were connected. One (1) gram Ancef was given IV and bony prominences were well padded.  SCD's were placed on both lower extremities. She was then administered general anesthesia and intubated. The right shoulder was examined under anesthesia and found to have a ROM of 180 degrees of forward flexion and abduction, 90 degrees external rotation with the arm at the side and when abducted, and 90 degrees internal rotation with the arm abducted. These findings were all symmetric to the unaffected side and at this point in time the patient was sat up in a beach chair position with her head held in a well-padded neutral fashion and the RUE was prepped and draped in a standard surgical fashion. Bony landmarks and incisions were drawn on the skin. After appropriate surgical timeout 
was performed to confirm the patient as Fawzia Elkomy and to confirm the right shoulder as the correct site. The subcutaneous tissue was infiltrated with approximately 10 cc 0.25% Marcaine w/epinephrine.  

A posterior portal was used to gain access into the joint and diagnostic arthroscopy began with evaluation of the 
rotator interval with a thickened and synovitic appearance to it. We established an anterior portal under direct visualization and inserted an arthroscopic probe evaluating the anterior, inferior and posterior labrums which were all intact. There was a chondral flap tear at the posterior inferior aspect of the glenoid and this was debrided with an arthroscopic shaver completing the chondroplasty with an arthroscopic biter. The remainder of the glenoid was intact, as was the chondral surfaces of the humerus. The superior labrum had fraying consistent with a SLAP tear and there was evidence of an auto biceps tenotomy without any biceps tendon evidence attached to the glenoid. 
The arthroscopic shaver was used to debride the superior labrum, in addition to the synovitis in the superior aspect of the glenoid, and then we evaluated the axillary recess which was free and clear of any loose bodies. The posterior RC was intact, as was the posterior mid portion of the RC. However, the anterior infraspinatus had some partial thickness tearing and there was complete full thickness tearing of the supraspinatus tendon. The subscapularis tendon was noted to be torn completely from its lesser tuberosity attachment and retracted back to about the medial aspect of the humeral head. We established a lateral portal under direct visualization and prepared the lesser tuberosity footprint down to bleeding bone. We also noted impingement of a prominent coracoid and we used our tissue ablator to outline the coracoid and then performed an appropriate coracoplasty decompressing the subscapularis tendon. We then placed two Mitek 5.5 mm Helix-BR suture anchors double loaded with #2 Orthocord suture in appropriate position on the lesser tuberosity and used a suture passing device to pass mattress sutures securing the subscapularis back down with a sliding knot and three alternating half-hitches. When we had restored the subscapularis to its anatomical footprint we then removed the scope from the glenohumeral joint and proceeded into the subacromial space. A significant amount of bursitis was encountered and a full bursectomy was performed in both the subacromial and subdeltoid recesses. We identified a type II acromion with a large anterior inferior hook and outlined this with an arthroscopic ablator and then used the arthroscopic bur in two planes to convert this to a type I configuration. Stenosis and hypertrophy fo the AC joint was noted and the decision was made to proceed with an arthroscopic Mumford at the end of the procedure. We identified our RC tear which was crescent-shaped without significant retraction and was mobile. However, there was undersurface delamination to the cuff. We prepared the greater tuberosity footprint down to bleeding bone and established an accessory posterolateral portal under direct visualization and then localized and identified our appropriate deadman's angle to place our suture anchors and then placed two Mitek Helix 5.5 mm suture anchors in the lateral footprint. We used the ExpresSew device to pass four simple sutures and then secured these down with a sliding knot and three alternating half-hitches thus restoring our RC back to its bony attachment. When this was completed we confirmed a watertight seal and a tension free repair. We then turned our attention to our AC joint. 
We performed an appropriate Mumford decompressing the AC joint and when this was completed we removed our instruments from the subacromial space and injected an additional approximately 15 cc 0.25% Marcaine w/epi. 

Next, we closed our incisions with 4-0 Monocryl suture in the subcuticular layer and used Dermabond to approximate the skin. A sterile dressing was then placed. The drapes were removed. The arm was placed in an Ultra sling. 


I coded this surgery to Medicare as follows:

29827,29826,29824, & 29999 for the biceps tenotomy.  Medicare has denied the 29999 citing ASC's can't use this code.

Did I code this procedure correctly and what is Medicare's rule on unlisted procedure codes?  How do I handle these in the future?

Any input is greatly appreciated!


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## OCD_coder (Mar 26, 2012)

I couldn't support billing a biceps "auto" tenotomy with a 29999.  First, the MD did not list it as part of the surgical procedures, so how could you defend this as actually being done.

Documentation:
There was a chondral flap tear at the posterior inferior aspect of the glenoid and this was debrided with an arthroscopic shaver completing the chondroplasty with an arthroscopic biter. The remainder of the glenoid was intact, as was the chondral surfaces of the humerus. The superior labrum had fraying consistent with a SLAP tear and there was evidence of an auto biceps tenotomy without any biceps tendon evidence attached to the glenoid. 

I am reading this op report that as a result of the debridement 29822 of the glenoid (which by the way I don't see as utilized, but was clearly performed) and the biceps tenotomy was an after effect or result or finding of/from the debridement/chondroplasty.  Verbiage of "evidence of an auto biceps tenotomy" is not sufficient documentation for me to support a 29999.  What tool was used to perform the procedure on the bicep tendon?

And no ASC's do not get reimbursed for unlisted codes, they patient needs to go to an outpatient facilty instead.


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## dyoungberg (Mar 30, 2012)

Guru-thanks so much for your input.  Now that I go back and look at this again, I see where I was wrong.  Thanks for helping out a newbie!


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