Orthopedic Coding Alert

Shoulder pain associated with adduction activitiese.g., golf swing, carrying a heavy tray above the shoulder with one handoften indicates a problem with a clavicle. Acromioclavicular (AC) joint arthritis is such a problem, and a common one.

But there are other problems as well. For example, a fall that pushes the scapula down causes it to tear the AC ligament and displace the clavicle. Or the clavicle might be deformed as a consequence of radiation therapy administered to treat childhood cancers (a well-known side effect).

Removal of the distal clavicle (partial claviculectomy) brings pain relief to many patients, particularly those with osteoarthritis. The excision of one-half inch or less of the distal clavicle encourages the development of scar tissue. And that tissue takes on the role of a (false) joint.

Distinguishing Between Open and Closed Approach

Partial claviculectomy, also known as distal clavicle resection, can be accomplished through open or arthroscopic procedures. The open procedure requires an incision of at least two inches.

The CPT code for partial claviculectomy is 23120 (claviculectomy; partial). But the code only applies to an open procedure.

If the surgery is done with a scope procedure, it must be a 29909 (unspecified procedure, arthroscopy), cautions Susan Callaway-Stradley, CPC, CCSP-P, an independent coding consultant who was recently named the American Association of Professional Coders coder of the year. And the steps must be described.

One such arthroscopic procedure is known as the Mumford, which uses three standard portals. It includes six steps.

Sandra A. Thomas, a coding and billing consultant based in Houston, TX, echoes Callaway-Stradleys recommendation. Moreover, she says, The 23120 only applies if other measures are not part of the surgery. If there is a more radical procedure [cf. below], another code [will apply]. And if a 29909 is used, the operative report must be included.

Supporting the CPT

The CPT must be supported by an appropriate diagnosis code. For example, for osteoarthritis at the AC joint, 715.31 (osteoarthrosis, localized, shoulder region) can support the claviculectomy procedure.

If the procedure is unilateral, indicate it with an -LT (left side) or -RT (right side) modifier. And if it is bilateral, use the -50 modifier.

Proper coding aside, a harsh surprise awaits claimants who file for reimbursement for a bilateral partial claviculectomy. Medicare C will not reimburse extra for the bilateral procedure, says Callaway-Stradley. It will reimburse at 150 percent for a bilateral total claviculectomy. But a bilateral partial is paid at the same amount as a partial on one side.

Most commercial payers follow the lead of Medicare C, so this is a loss for most claimants.

Total Claviculectomy

Because the clavicle is fixed rigidly to the sternum, a total claviculectomy is usually necessitated by extensive trauma or other severe condition (e.g. bone metastasis). It is extensive and would be performed through an open procedure. It is coded 23125 (claviculectomy total).

Partial Claviculectomy with Another Procedure

Callaway-Stradley points out that often the excision of a piece of the distal clavicle is tied to some other procedure in the shoulder. Examples are acromioplasty and rotator cuff repair. If a separate excision (or better, site entry) can be documented for the partial claviculectomy, a -59 modifier (distinct procedural services) may apply.

Note: Check with your carrier on this one because the -59 modifier raises flags.

Callaway-Stradley also notes the clavicle is sometimes smoothed off or rounded as part of another procedure. Such approaches raise the question of how much do you have to cut off to have a partial claviculectomy?

The answer is, at least a portion, and the intent to do so (i.e. the diagnosis) will help to support the claim of partial claviculectomy. Adding to documentation woes is the conflicting and changing perspectives among orthopedic surgeons on the value of the claviculectomy.

The entire issue of whether part of the clavicle should be excised has become a touchy subject, explains Callaway-Stradley. OCA looked at some of the literature about outcomes, and orthopedic surgeons conclude the intervention can be valuable but it is not always justified.

For example, sometimes a bone shift, such as a fall on a shoulder that pushes down the scapula, also displaces the clavicle at the AC joint. In this instance the partial claviculectomy is particularly controversial because excising a piece of the clavicle will not do much for pain. The reason: The clavicle will still be displaced (unable to meet the scapula); it will just be shorter.

Partial Excision of Clavicle, Fractured Clavicles

Code 23180 (partial excision clavicle) looks similar to 23120. But its scope is quite different and includes excision necessitated by several sorts of bone disease. Code 23120 applies more to excision because of compression events, explains Callaway-Stradley. A piece of the clavicle is cut off. Often, with the bone disease, more is done. For example, a piece is cut off and there is a scraping out of the interior of the clavicle.

In a special case, clavicle reduction might be part of fracture repair. (Fractured clavicles result largely from falling and landing, catching oneself, on a hand or from the deployment of seat belt harnesses accidents both, which need to be coded as such in diagnoses.) In such a case there is a separate code for a clavicle reduction that occurs with an open clavicle repair, 23515 (open treatment of clavicular fracture, with or without internal or external fixation).