Orthopedic Coding Alert

As more and more orthopedic surgeons embrace arthroscopy as the most effective tool for diagnosing and treating shoulder pathology, reimbursement issues arise when the procedure cannot be completed arthroscopically. Although arthroscopy is an additional step that ensures a fully visualized surgical area, carriers are usually unwilling to reimburse surgeons for both the open and arthroscopic portions of a surgical procedure.

Changing Procedures

A typical arthroscopic shoulder surgery is coded with CPT 29826 (arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release). The orthopedist may consider performing the entire procedure arthroscopically with the knowledge that an open repair may be required. The view through the arthroscope does indeed reveal that a rotator cuff repair (23410, repair of ruptured musculotendinous cuff [e.g., rotator cuff]; acute) is required. The surgery then switches from an arthroscopic approach to an open repair.

Another typical scenario occurs when the orthopedist uses the arthroscope to attain an enhanced view of the operative site. Arthroscopically, the surgeon can better visualize the intra-articular structures of the shoulder joint. This is particularly true in cases of suspected rotator cuff damage. The two spaces of the rotator cuff, the glenohumeral (undersurface of rotator cuff) and the bursa superior (top of the rotator cuff), are clearly visible through the arthroscope. If the surgeon relies solely on the view afforded through the open procedure, he or she might not have as clear an idea of the work required to repair the damage.

For example, a patient with a history of an acute shoulder dislocation suffers a subsequent injury to the shoulder with recurrent subluxations. X-rays are negative. The surgeon performs a diagnostic arthroscopy to assess the shoulder pathology. This arthroscopic examination of the shoulder reveals that the subscapularis and bicep tendons are normal and the rotator cuff is intact, as are the superior, middle and inferior glenohumeral ligaments. No loose bodies are visualized, but the anterior glenoid labrum is torn and completely detached. At this point the surgeon determines that an anterior capsulorrhaphy with labral repair (23455, capsulorrhaphy, anterior; with labral repair [e.g., Bankart procedure]) is necessary. The arthroscope is removed, and the open procedure begins.

The question then becomes how to code and obtain reimbursement for both the diagnostic arthroscopy (29815, arthroscopy, shoulder, diagnostic, with or without synovial biopsy [separate procedure]) and the Bankart procedure (23455).

No Sure Path to Reimbursement

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., who has extensive experience in orthopedics, explains that when any procedure is started arthroscopically and switches to an open procedure, the open procedure should be billed.

The first issue is, if you start with a scope repair and switch to open, the open procedure takes precedence, Callaway says. The other issue is that in most cases, if you do a diagnostic scope and open surgical repair during the same session, you can only bill open.

Callaway explains that in the first surgical scenario, the mixed use of arthroscopy and open procedure is almost always planned in advance. Therefore the arthroscopic procedure (29826) did not specifically fail. It was a known possibility that arthroscopy alone might not be sufficient to complete the repair. The arthroscopy revealed that the open procedure (23410) was required. And because the open procedure is regarded as the more comprehensive of the two, it is the prevailing, and only billable code.

While that doesnt absolutely mean no reimbursement for the initial arthroscopy, it will be a challenge to convince payers to unbundle it from the open repair. The only possible method is to use 23410-22 (with the modifier for unusual procedural services), and submit the operative note and/or other written explanation from the surgeon to specify the additional work performed. The documentation should include a request for additional payment on top of the fee for 23410 depending on a reasonable judgment from the physician as to the amount of extra work entailed in the combined procedures.

Keep in mind, however, that the chance of a planned arthroscopy becoming an unplanned open procedure meaning the surgeon did not know in advance that he or she would have to switch to an open procedure is slight. The documentation must describe an unusual circumstance to justify beginning the procedure as a stand alone arthroscopy and then switching to the open procedure.

Diagnostic Arthroscopy is Usually Bundled

Obtaining reimbursement for both the diagnostic arthroscopy and the anterior capsulorrhaphy in the same surgical session is not straightforward either. According to the American Academy of Orthopedic Surgeons (AAOS) Complete Global Service Data Guide, 23455 includes a diagnostic arthroscopy (29815, arthroscopy, shoulder, diagnostic) as part of the global surgical package. It is worthwhile to note, however, that Medicare does not bundle the two procedures in the most recent CCI edits.

Still, according to Callaway, convincing carriers that the diagnostic aspect should be separately payable is a tall order. While theres no question that the scope affords the surgeon a better view of the surgical field, that doesnt really matter in the payers eyes, she says.

Callaway adds that the most straightforward cause for unbundling 29815 from the capsulorrhaphy is that the surgeon did not know in advance what the problem was, such as in the case described above. The only time you can justify billing the diagnostic arthroscopy and the open repair in the same session, she says, is when you use the scope to determine the problem, and as a result of the scope, decide on a surgery more comprehensive than was originally intended. In that case, the open procedure (e.g., 23455) would be billed on the first line followed by 29815-59 (with the modifier for distinct procedural service). The modifier -59 unbundles the arthroscopy from the open procedure, as it is usually included.

While this coding solution works for this particular scenario, experts agree this is an exception. According to Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm based in Spring Lake, N.J., While the orthopedic surgeon may use the arthroscope to get a better look at the damage to the shoulder, its unlikely that he or she wasnt already aware of the damage to the shoulder prior to taking the patient into surgery.

Callaway agrees. Chances are, she says, the surgeon has already used another diagnostic tool prior to the surgery, like magnetic resonance imaging (MRI) (73221, magnetic resonance [e.g., proton] imaging, any joint of upper extremity; without contrast material[s]) or an arthrography (73040, radiologic examination, shoulder, arthrography, radiological supervision and interpretation). If these methods have already diagnosed the torn and detached anterior glenoid labrum (840.8, sprain/strain of shoulder and upper arm; other specified sites of shoulder and upper arm), the diagnostic arthroscopy is not separately billable; it is viewed as a redundant procedure.

Sometimes, Callaway says, a qualifying circumstance may get you some reimbursement on the diagnostic arthroscopy. If documentation can demonstrate that a significant portion of work was done before the arthroscopy was stopped and the open procedure began, there may be a chance of some reimbursement. The documentation would have to prove, however, that the arthroscopy revealed information not previously discovered by other diagnostic procedures (e.g., MRI or arthrography) that impacted the surgeons decision for the remainder of the surgery. Under those specific circumstances, the capsulorrhaphy (23455) should be billed on its own (do not include 29815) with modifier -22.

The operative report and a letter explaining in laymans terms what was performed should also be included to justify the medical necessity of the additional work. But, Callaway cautions, be realistic about what you did with the diagnostic scope. Unless it presented you with new and decisive information, it is really not billable under any circumstances.

Coders submitting this type of claim should anticipate an initial denial from the payer, and should appeal if they feel that the extra work supports extra reimbursement.

Also, keep in mind that because of the AAOS guide, which indicates bundling these procedures, insurance carriers are likely to decide that use of the arthroscope was elective on the surgeons part, and not essential to the outcome of the surgery.