Orthopedic Coding Alert

A 54-year-old man, who suffers from rotator cuff impingement syndrome and acromioclavicular joint arthritis in the left shoulder, undergoes endoscopic repair of a partial rotator cuff tear.

Operative Report

Under the guide of a spindle needle, the orthopedist makes a standard posterior and anterior portal. He then begins systematic inspection of the joint, first with the glenohumeral joint. The op report reads: No significant cartilage changes noted. Some fraying of the superior labrum, but it was attached. Noted fraying of the biceps tendon and fraying of the rotator cuff at the rotator cuff interval, which was debrided with a shaver. No complete tear of the rotator cuff noted.

Next, he placed the arthroscope in the anterior portal and the rotator cuff was inspected from posterior to anterior. Again, no complete tears were noticed in the rotator cuff tendon.

Next, he removed the arthroscope from the glenohumeral joint and placed it in the subacromial space. The op report continues: The thickened bursa was debrided with a shaver. There was some fraying of the cuff but no tear noted. The coracoacromial ligament was removed with the Arthrocare wand and the acromioplasty was begun with a 6.0 pear-shaped bur.

Finally, in the acromioclavicular joint, the surgeon noted arthritic changes on the surface which he debrided with the bur. The op report reads: The Mumford was completed from the lateral portal and from the anterior portal.

Coding Challenge

As with many orthopedic procedures, the CPT hasnt caught up with technology when it comes to providing sufficient codes for endoscopic procedures. For example, the CPT contains numerous open repair codes for each musculoskeletal area, but little more than two pages of codes for all endoscopic and arthroscopic procedures (29800-29909).

Coders, who are tempted to stick with the familiar open code because it seems to describe the procedure better, are in danger of upcoding. An open procedure always pays more than its comparable endoscopic counterpart. For example, an open repair of the rotator cuff as described by 23420 (reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]) has a relative value unit of 19.0. But code 29826 (arthroscopy, shoulder, surgical; with removal of loose or foreign body, decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) has an RVU of 21.83.

Lets review the difference between an open and an endoscopic procedure. To perform an open surgery, the orthopedist makes an incision as well as closes it. For example, for the open shoulder repair, the incision over the acromioclavicular joint may be several inches long.

But with an endoscopic procedure, small punctures about a half-inch long are made through which to place a lighted fiber optic instrument, or arthroscope. For example, code 29826 includes the surgeon making [...]