Orthopedic Coding Alert

Can you bill acromioplasty or subscapularis separately? Read on to find out

Shoulder surgery has become one of the most popular sub-specialties in orthopedics, and with the proliferation of arthroscopic procedures, many coders are puzzled about exactly how to code the surgeries. Increase your coding accuracy by learning about the anatomy of the shoulder and the specifics of some newer procedures.

Get Familiar With Shoulder Anatomy

Surgeons often refer to anatomic sites in their op reports, so it can be difficult to select the right codes unless you know your anatomy. This quick primer can help dissolve any coding confusion.
 
The shoulder girdle consists of three joints and two articulations. The joints are 1) the gleno-humeral joint, which is what most people generically refer to as -the shoulder joint,- 2) the acromio-clavicular joint (usually abbreviated to AC joint) and 3) the sterno-clavicular joint (often seen as SC joint). The articulations are classified as such because they are not true synovial joints and are not completely bounded by ligaments. The articulations are 1) the acromial-humeral articulation, more commonly called the sub-acromial space, and 2) the scapulo-thoracic articulation, or the articulation between the ribs and the shoulder blade.
 
Learn the clock-face analogy: Looking at a cross-section of the gleno-humeral joint, surgeons often describe some of their procedures by analogy to a clock face. Thus, you may see -The labrum was torn between 4 and 6 o-clock.-
 
If you imagine a clock face superimposed on the cross-section of the glenoid fossa only, on the right shoulder the anterior aspect of the joint will be from 12 to 6, while on the left shoulder the posterior aspect will be from 12 to 6. The clock face analogy is used to describe tears of the labrum or work done on certain sections of the gleno-humeral joint capsule.
 
The rotator cuff is a series of four muscles that surrounds the gleno-humeral joints -- almost completely. The muscles are the 1) subscapularis, 2) supraspinatus, 3) infraspinatus and 4) teres minor. The subscapularis is the largest muscle and is anterior. The supraspinatus is the muscle most commonly torn and is superior. The infraspinatus and teres minor are the posterior muscles.
 
You may also see the term -the rotator interval.- This is the antero-superior space between the anterior edge of the supraspinatus and the superior edge of the subscapularis, and is the only space where the rotator cuff does not completely invest the gleno-humeral joint.
 
Posteriorly, the interval between the supraspinatus and the infraspinatus is often termed the -posterior rotator interval,- but this is much less discrete. In fact, posteriorly, it is difficult to tell where one muscle starts and one ends when performing arthroscopic surgery.

Look at 4 Options When Coding RCRs

The rotator cuff is the most common source of shoulder pain in anyone over 30 years old and is the most commonly torn tendon in the body. Repairing the rotator cuff is always listed among the 10 most commonly performed orthopedic procedures. Until the late 1990s, this repair was always done via an open procedure with about a 5- to 8-centimeter incision, taking apart the deltoid muscle to expose and repair the rotator cuff. In many places, it is still performed this way.
 
But since the late 1990s, it has become possible to perform arthroscopic rotator cuff repairs (RCR). Some surgeons, not yet fully versed in arthroscopic techniques or for matters of personal preference, perform what is termed a -mini-open rotator cuff repair.-
 
In this technique, the surgeon performs an arthroscopic acromioplasty, and the cuff edges and bony attachment are prepared arthroscopically. The surgeon then makes a small incision -- often only 1.5-3 centimeters -- and repairs the tendon using bony suture anchors.
 
So how should you code these procedures? There are four possibilities. In addition, an acromioplasty, or shaving of the undersurface of the acromion (superior edge of the scapula), is often performed concurrently. Coders often wonder: Can you code this separately, or isit bundled?
 
The possible codes are:
 
- 23130 -- Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release
 
- 23410 -- Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute 
 
- 23412 -- Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic
 
- 23420 -- Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)
 
- 29826 -- Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release
 
- 29827 -- Arthroscopy, shoulder, surgical; with rotator cuff repair.

Know Acute and Chronic Repairs

For open procedures, coders are often confused as to when they should use 23410, 23412 or 23420. Part of this depends on the definition of -acute.- 
 
For most coding situations, -acute- describes an injury less than three months old. As a shoulder surgeon, I can assure you that we rarely see patients with rotator cuff tears that are acute. Most patients hurt their shoulder more than three months previously, saw their primary-care doctor, went to a physical therapist for a while, maybe got an MRI, and then were referred to the orthopedist.
 
By the time we get the patient to surgery, we are almost always treating a chronic tear. Unless your surgeon specifically documents that the patient's injury occurred less than three months from the date of surgery, 23412 is probably going to be used in most cases.
 
But when would you use 23420 for open repairs? There are no hard and fast guidelines. One thing to remember is that more than one rotator cuff tendon can be torn. We often term these as 2-tendon tears, or 3-tendon tears -- or rarely 4-tendon or massive tears, though those are often irreparable. I would use 23420 for any multi-tendon repair, which needs to be documented by your surgeon. And no, there is no extra code for repairing more than one tendon -- it is 23420 only for those repairs.
 
When can you also code the acromioplasty? With open repairs, you really can't as of 2006. As noted above, by definition 23420 includes the acromioplasty. And as of 2006, the National Correct Coding Initiative edits bundle 23130 and 23410/23412/23420. Prior to 2006, you could separately code 23130 with 23410 and 23412. Although it carries a -1- indicator, I doubt this will be allowed even with modifier 59 (Distinct procedural service). 
 
About that subscapularis repair: An oft-asked question concerns repair of the subscapularis. This is the least commonly torn rotator cuff tendon. To fully repair a complete tear of the subscapularis, one should probably still do this procedure open because of some neurovascular concerns. But it is still -only- a rotator cuff repair. You would choose one of the codes above for RCRs.

If your physician repairs the subscapularis and any of the other tendons, you cannot add extra codes for this, even if he repairs some arthroscopically and some open. It is still -simply- a rotator cuff repair.

Documentation Determines Debridement Type
 
CPT offers two codes for arthroscopic debridement:
 
- 29822 -- Arthroscopy, shoulder, surgical; debridement, limited
 
- 29823 -- ... debridement, extensive.

The AAOS has produced a position statement to distinguish between these two codes, because the difference was previously not well described. Limited debridement (29822) occurs when the surgeon debrides tissue only in the anterior part of the gleno-humeral joint, or the posterior part of the gleno-humeral joint, or the sub-acromial bursa.
 
Report the extensive debridement code (29823) when the surgeon performs arthroscopy debridement in both sections of the gleno-humeral joint or in any part of the gleno-humeral joint and the sub-acromial bursa. So documentation by your surgeon is critical here.

Bankart Usually Includes Capsulorrhaphy

Similar to the rotator cuff, surgeons often perform arthroscopic procedures to reconstruct unstable shoulders. The classic procedure for this is termed a -Bankart repair,- in which the surgeon repairs a tear of the antero-inferior labrum (the fibrocartilaginous lining of the glenoid fossa), termed a Bankart lesion. In addition, the surgeon tightens the anterior capsule whether done open or arthroscopically, and this is a separate anatomic structure from the labrum.
 
If your surgeon performs arthroscopic stabilization, it is important that he document  whether a capsulorrhaphy was performed as part of the procedure (it often is.) A true arthroscopic Bankart procedure should contain both a labral repair (29807) and a capsulorrhaphy (29806), which can be done in several ways arthroscopically -- imbrication of the inferior gleno-humeral ligament and rotator interval closure being the most common.
 
However, as of July 2004, the NCCI bundles the procedures together with a -1- indicator. You can separately report both procedures by appending modifier 59 to 29806, but the key will be complete documentation by your surgeon that these were performed as separate procedures -- for example, if the physician performed the labral repair in one region of the shoulder and the capsulorrhaphy in another.

Educate Your Surgeon

If you-ll notice above, I have emphasized several times that the key point is usually the surgeon's documentation. I sympathize with coders who have to interpret an op note that does not correlate well with a CPT code.
 
I-m a surgeon, but I think all coders should tell their surgeons that they need to document their procedures more accurately -- both to help the coders and to increase their collections. Go ahead, you have my permission! 

 -- About the author: Bill Mallon, MD, is a practicing orthopedic surgeon and the medical director at Triangle Orthopaedic Associates in Durham, N.C.