Orthopedic Coding Alert

Not every SLAP lesion debridement claim will warrant separately reporting 29822

If you bemoan coding arthroscopic shoulder surgeries - particularly those that include separate SLAP lesion debridement - a few minutes brushing up on the basics could be just what you need to improve your SAD coding skills.
 
Take a look at the following arthroscopic subacromial decompression (SAD) operative note and review our experts' coding recommendations.
 
Procedure Overview: See What the Surgeon Performed

Here's a quick synopsis: A 37-year-old male patient with left shoulder pain has severe acromioclavicular osteoarthrosis (715.91), impingement and tendonitis (726.2). The orthopedic surgeon performed left shoulder arthroscopy, arthroscopic SAD, an arthroscopic Mumford procedure, and a bilateral shoulder examination.
 
Additional Procedure: The surgeon also debrided a type I superior labrum anterior and posterior (SLAP) lesion.

Operative Note: Trace the Surgeon's Work

The pertinent details from the operative report: The surgeon established standard anterior, posterior and lateral arthroscopic portals. On the glenoid side, the patient had a 4-mm, grade-2B lesion. The central aspect of the glenoid was without any loose flaps, circumferentially. No evidence of any loose bodies. Patient had a negative drive-through sign, negative peel-back sign. Biceps tendon and biceps anchor intact. Patient had a type I SLAP. This was debrided with arthroscopic shaver. Patient's rotator cuff and subscapularis were intact; labrum otherwise intact.
 
We carefully inspected the labrum from both posterior and anterior portals and saw no evidence of posterior labral tear or posterior capsular tear. Patient had a patulous axillary recess. No notable synovitis superiorly. We then went to the subacromial space. Dense bursal adhesions and tissue were demonstrated. We debrided this out with arthroscopic shaver and ArthroCare device. Patient had moderate subacromial prominence. We performed an arthroscopic subacromial decompression from both portals. Confirmed from both portals. Excellent decompression, including the release of the CA ligament. AC joint with osteoarthrosis and inferior osteophytes.
 
We performed a distal clavicle resection of 8-9 mm, preserving the ligaments. All debris removed. Irrigated all material from the subacromial space. Carefully inspected the rotator cuff from the bursal side and found no evidence of tearing there. Closed with 2-0 nylon sutures.

Coding Advice: Follow These 4 Steps

Step 1: Code the Main Procedure. First report 29826-LT (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; Left side). You should link this code with 726.2 (Rotator cuff syndrome of shoulder and allied disorders; other specified disorders), says consultant Annette Grady CPC, CPC-H, with Eide Bailly in Bismarck, N.D.
 
Step 2: Code the Arthroscopic Mumford Procedure. You should report 29824-LT (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure]) to represent the surgeon's work performing the distal clavicle resection. You should link this procedure to 715.91 (Osteoarthrosis, unspecified whether generalized or localized; shoulder region), Grady says.
 
Step 3: Examine SLAP Lesion Documentation. Because the National Correct Coding Initiative (NCCI) includes limited debridement (29822, Arthroscopy, shoulder, surgical; debridement, limited) as an edit with 29826, some coders hesitate to report this procedure separately. The American Academy of Orthopaedic Surgeons (AAOS), however, says that you can report 29822 in addition to 29826 (see our article "Arthroscopic SAD Edits Vary According to Source" on page 91 for more information on edits). Therefore, your decision on whether to report 29822 with 29826 will depend on several factors.
 
First, determine whether you're billing Medicare (which follows NCCI edits) or a payer that follows the AAOS' guidelines. Second, ask the surgeon whether he debrided the subacromial space simply for visualization, which most payers would include in the main procedure (29826) no matter which payer you're billing, or whether he moved the scope and treated separate structures, which most consultants believe you should document before you report 29822 separately.
 
Expert Advice for Our Op Report: "I would report 29822 for debridement of the labrum in this case," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J. "When the labrum is debrided, the scope is in the glenohumeral joint, but the scope is moved to the subacromial space to perform the subacromial decompression. Both AAOS and AMA/CPT guidelines support reporting both codes in this scenario."
  
If Your Surgeon Chooses to Report 29822: Even when you believe you shouldn't report 29822 with your SAD claim, your surgeon may disagree. "Ultimately, the surgeon is responsible for correctly coding the claim, so you should ask him whether he believes the SLAP lesion debridement was a separately identifiable procedure," says Jay Neal, an independent coding and billing consultant in Atlanta. If the surgeon chooses to report both procedures, you should bill 29822-59 (Distinct procedural service) to payers that follow NCCI edits (such as Medicare). If your payer does not follow NCCI edits, you should report 29822-51 (Multiple procedures).
 
If you do bill 29822, you should link it to 718.31 (Recurrent dislocation of joint; shoulder region).
 
Step 4: File the Assistant Surgeon's Claim. If you report 29826 and 29824 for the orthopedic surgeon's work, you should then bill 29826-AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) and 29824-AS for the surgical assistant, Grady says.
 
If another physician assists (not a nonphysician practitioner), you should instead report 29826-80 (Assistant surgeon) and 29824-80.