Advanced Search

Orthopedic Coding Alert

Avoid Multiple Headaches When Coding Multiple Arthroscopic Shoulder Procedures

Published on Wed Aug 01, 2001

Orthopedic coders consistently cite coding for multiple arthroscopic shoulder procedures as a source of frustration. Too few codes and too many denials cause many coders to expect the worst when it comes to reimbursement. While technological advances in shoulder surgery allow surgeons to perform many procedures arthro-scopically that were formerly done as open procedures, CPT codes do not exist for many of these procedures. Coders must use the unlisted arthroscopy procedure code (29909) to report the surgical services rendered.

A Plan of Attack
 
When confronted with an operative report that indicates three, four or more arthroscopic procedures performed in one operative setting, the coder's first instinct may be to put it in the bottom of the "in-box" for another day. Having a game plan to approach a daunting operative report is more proactive. But how does one assign codes for a surgery that lacks CPT codes?
 
Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., has an approach that works well for her practice. "When I have an arthroscopic procedure that includes multiple unlisted procedure codes, I first code the procedures as if they were open and list the analog codes that would apply if this were the case," Stout says. Analog codes reflect a similar amount of work and outcome to the procedure in question but do not describe that procedure. Stout then lists the codes by relative value with the highest relative value unit procedure first in descending order. "Next, I check the American Academy of Orthopedic Surgeons (AAOS) Complete Global Service Data Guide to see what procedures are considered components of the primary procedure and go from there," she says.

Surgical Example
 
The following operative report illustrates Stout's approach to coding multiple arthroscopies. The patient's preoperative diagnosis was chronic rotator cuff tear of the right shoulder (840.4) and degenerative arthritis in the right acromioclavicular joint. Four procedures were performed:
 
  • Arthroscopic repair of rotator cuff tear with one side-to-side suture and two Bio-Corkscrew suture anchors;

  • Arthroscopic biceps tenodesis of right shoulder with one Bio-Corkscrew suture anchor;
     
  • Arthroscopic acromioplasty, right shoulder and
     
  • Arthroscopic excision, right distal clavicle.
    •  
    If the surgeries had been performed as open repairs, the orthopedist would code 23412 (repair of ruptured musculotendinous cuff [e.g., rotator cuff]; chronic), 23430 (tenodesis of long tendon biceps), 23130 (acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release) and 23120 (claviculectomy; partial).
     
    According to the AAOS guide, 23130 is bundled with 23412, but 23430 and 23120 can be reported in addition to 23412. "Armed with this information," Stout says, "calculate an acceptable fee for the procedure by adding the fees for 23412, 23430 and 23120 together." If your practice has a contract with the patient's carrier, request the contracted amount for the three open procedure codes, with an additional percentage for the increased complexity of the arthroscopic approach. If the practice is not contracted with the carrier, request the practice's customary fees for the three open procedures, with an additional percentage for the increased complexity of the arthroscopic approach.

    Unlisted is Still the Only Option
     
    Stout's approach to coding the surgery arrives at a reasonable charge and shows the carrier exactly what was done in the operative setting. But when the claim is submitted to the carrier, the open or analog codes are for illustration purposes only. The unlisted procedure code 29909 (unlisted procedure, arthroscopy) is still the only one that can be submitted for this complex surgery.
     
    Coders should submit a KISS (keep it short and simple) letter with the claim for 29909, and the operative report. The KISS letter should list the procedures that were performed arthroscopically, comparing the arthroscopic procedures performed to the open procedure codes and highlighting the differences that increase the complexity of the procedure. Rather than let carriers set the fee (which they will do anyway), request a specific reimbursement amount for the procedure and be prepared to appeal should the claim be rejected initially.
     
    When reporting multiple unlisted procedures performed at the same anatomic site, it is necessary and appropriate to report the unlisted procedure code only once. Whenever possible, be proactive with the patient's carrier and negotiate reimbursement before the surgery rather than after.

    Other Articles in this issue of

    Orthopedic Coding Alert

    View All