Anesthesia Coding Alert

Question: A 62-year-old female is diagnosed with primary osteoarthritis of the right shoulder. The orthopedic surgeon performed a right total shoulder arthroplasty, replacing both the glenoid and the humeral head with a prosthetic joint. Prior to the surgery, the surgeon gave a written order to the anesthesia department requesting they manage the patient’s expected postoperative pain.

The pre-anesthesia record indicates the anesthesiologist planned to personally perform general anesthesia for the arthroplasty and a brachial plexus block for postoperative pain management. The procedure note for the brachial plexus block indicates the anesthesiologist used ultrasound guidance and placed it prior to induction of the patient. There are ultrasound images retained in the medical record and a full report showing use of ultrasound imaging during the block.

What diagnosis and procedure codes should the surgeon assign? What diagnosis and procedure codes should the anesthesiologist assign?

AAPC Forum Participant

Answer:  The surgeon should report 23472 (Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))) for the right total shoulder arthroplasty.

Diagnosis roundup 1: The ortho reported primary osteoarthritis in the right shoulder as the indication for surgery, coded with M19.011 (Primary osteoarthritis, right shoulder).

ASA code: In this case, the appropriate anesthesia code to report for the shoulder surgery is 01638 (Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement) with modifier AA (Anesthesia services performed personally by anesthesiologist) appended.

Block: For the brachial plexus block for post-op pain management, use 64415 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed). Append a modifier, such as -XU (Unusual non-overlapping service …) or -59 (Distinct procedural service), depending on payer preference to indicate the block is separate from the anesthesia for surgery.

Diagnosis roundup 2: For the general anesthesia, use M19.011. To support the brachial plexus block, submit G89.18 (Other acute postprocedural pain) and/or M25.511 (Pain in right shoulder).

Tip: To support your claim for the block, some payers require a pain diagnosis, while others require a diagnosis of other acute postprocedural pain. Both are acceptable diagnosis codes, so if you submit both, you have all your bases covered.

Double-check the claim to ensure the diagnosis associated with 01638 is osteoarthritis (M19.011) and those associated with 64415 reflect its necessity for control of postoperative pain in the right shoulder.

Don’t miss: As of Jan. 1, 2023, ultrasound is no longer separately billed with a brachial plexus block, as indicated in the code’s descriptor: “including imaging guidance, when performed.”