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 two to four small poke-hole incisions around the shoulder joint. Other instruments also may be inserted through these poke holes to cut, shave, repair, or drill during the procedure.

Note: When a diagnosis cannot be made from information provided by the patients history and physical, or arthrogram, an arthroscopy must be performed in order to visualize the interior shoulder and determine a diagnosis. In that case, you would use 29815 (arthroscopy, shoulder, diagnostic, with or without synovial biopsy). However, a diagnostic arthroscopy is always included in a surgical arthroscopy as part of the intraoperative services in the global service package. The rationale is that all the initial steps that must be done for a diagnostic arthroscopy must also be done for the surgical arthroscopy. The steps are extensive enough that once the orthopedist is in the shoulder joint, he or she wont merely do a diagnostic procedure and come back a few days later to perform the surgical one. Instead, the orthopedist will proceed directly to the surgical procedure while inside with the endoscope. Therefore, the diagnostic arthroscopy is not separately reimbursable.

Coders Opinions

There has been some confusion in determining how to code this procedure. Below are two common ways coders submit these claims, but they are not reimbursed for the following reasons.

Some coders suggested coding 23420 (reconstruction of complete shoulder [rotator] cuff avulsion) along with 29823 (arthroscopy, shoulder, surgical, debridement, extensive). However, the procedure was an endoscopic one, not an open one, so the 23420 would be considered upcoding. Therefore, it should not be used.

Other coders recommend using code 23120 (claviculectomy, partial) along with 29826 (arthroscopy, shoulder, surgical; with removal of loose or foreign body, decompression of subacromial space with partial acromioplasty with or without coracoacromial release). However, this code combination would be inappropriate for two reasons.

First, code 23120 is an open procedurenot an endoscopic onethat represents partial removal of the collar bone through an incision along the part of the bone that is to be removed. The surgeon pulls the skin back, divides the bone with an osteome, and rounds off the tip to eliminate the rough edge. He or she also divides the ligament that connects the clavicle to the adjacent bone and removes the bone.

Secondly, even if coding conventions allowed an open code to be used for an endoscopic procedure, the op report did not provide enough documentation to bill for the claviculectomy. For example, the note merely stated the Mumford was completed from the lateral portal and from the anterior portal. There is no step-by-step description of what actually occurred.

Note: We noticed one of the procedures listed on the original op report was arthroscopic resection distal clavicle. However, this was not documented in the narrative. Remember, an auditor relies on what is actually documented, not the names of procedures or physicians jargon within the documentation. Therefore, dont append a -59 modifier (distinct procedural service) to 23120. It might get you paid the $428 because this modifier overrides system edits, but it also may get you in trouble.

Coding Solution

The procedure described in the op note is actually closer to 23130 (acromioplasty or acromionectomy partial), which includes codes 29826 (arthroscopy, shoulder, surgical; with removal of loose or foreign body, decompression of subacromial space with partial acromioplasty) and 29823 (arthroscopy, shoulder, surgical, debridement, extensive). However, 23120 is a code for an open surgical process and cant be used in the present endoscopic case.

Because code 29826 is most like 23130 and represents an endoscopic procedure, use this code for the surgical arthroscopy.

For debridement of the biceps tendon, the bursa of the subacromial space and the bursa in the AC joint, use 29823.

While code 29826 pays about $645 and the 29823 pays about $590, the practice wont recoup the total fee of $1,235. The way most payers figure reimbursement for endoscopies is that the most expensive one is paid in full. But the reimbursement for the second procedure equals its allowable minus the fee for the base endoscopy. For example, 29815 (arthroscopy, shoulder diagnostic; with or without synovial biopsy) pays $378, so the debridement would be figured as $590 minus $378, or $212. Hence, the total reimbursement would be $645 plus $212, or $857.

Since these two procedures are from the same endoscopic family, endoscopic payment rules will apply for Medicare and most major carriers. For example, dont append a modifier -51 on multiple arthroscopies done in the same family of codes, or youll reduce by half the amount that is being reimbursed for the second procedure. (In CPT, a family is designated by a non-indented code followed by a group of indented codes. For example, codes 29819 through 29826 comprise one family of codes.)

Therefore, your choice is to code as follows:

1) 		29826		726.10 	(rotator cuff syndrome)
2) 		29823 		726.10

Be careful when selecting diagnostic codes for rotator cuff. For example, rotator cuff tears can be due to a sprain, in which case you would use 840.4 (sprains and strains of shoulder and upper arm, rotator cuff, capsule).

Note: If the documentation for the Mumford had been better, a more comprehensive serviceand a higher reimbursementmight have been coded with modifier -22 (significant separate procedure) or an unlisted code (29909). Even if you used an unlisted code for the Mumford, the payer could not evaluate reimbursement based on the poor documentation in this instance.

Editors note: Sources for this article include Susan Callaway Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, an accounting and consulting firm in Augusta, GA; Aspen Publishers CPT Made Easy; Medicodes Medicare Billing Guide and Coders Desk Reference; 1999 CPT Manual and ICD-9-CM.

Terminology Acromioclavicular (AC) joint arthrosis: Degenerative arthritis in the acromioclavicular (AC) joint. A common problem in shoulders with rotator cuff tear. Acromion: The highest point of the shoulder blade that connects with the collarbone. Part of the acromioclavicular joint. Bursa: Lubricating tissue that lies on the surface of the rotator cuff tendons. The tendons and bursa normally glide smoothly between the acromion and the top of the humerus, the upper arm bone. Impingement syndrome: Occurs when the space between the undersurface of the acromion and the top of the humeral head is quite narrow. When the arm is raised in a forward position, the rotator cuff tendon and the bursa are pinched. When this occurs repeatedly, the tendons and bursa can become inflamed and swollen. This syndrome, chronic impingement, can be very painful. Rotator cuff: A set of four muscles that originate on the scapula, or shoulder blade, and turn into flat, fibrous tendons as they surround front, back, and top of the shoulder jointlike a cuff on a shirt sleeve. When these muscles contract, they pull on the rotator cuff tendon, allowing the shoulder to move through a wide range of motion. Rotator cuff disease: When chronic impingement syndrome continues to affect the rotator cuff and tendon, the tendon may actually begin to break down near its attachment on the humerus bone. After more and more damage occurs, the tendon may finally tear completely away from the bone.