Orthopedic Coding Alert

Question: In a patient diagnosed with posterior labral tear, subacromial bursitis with impingement type lesion, multidirectional instability, and partial infraspinatus tear and impingement lesion, our surgeon did the following procedures:

1.   Arthroscopic repair of the posterior labrum.

2.   Arthroscopic minimal subacromial decompression with subacromial bursectomy and CA ligament release.

3.   Arthroscopic debridement of partial infraspinatus tear.

How do we report these procedures?

Ohio Subscriber

Answer: You report 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) for arthroscopic repair of the posterior labral tear. The suitable diagnosis code for this can be 718.81 (Other joint derangement not elsewhere classified involving shoulder region). Since your surgeon is also doing a subacromial decompression and ligament release, you report +29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e., arch] release, when performed [List separately in addition to code for primary procedure]). Lastly, your surgeon is doing a debridement for which you report 29823 (Arthroscopy, shoulder, surgical; debridement, extensive) provided your surgeon documents the extent of the debridement. As per AAOS, extensive debridement is one that is done in the anterior and posterior aspects of the glenohumeral joint. You may report limited debridement with 29822 (Arthroscopy, shoulder, surgical; debridement, limited) and append modifier 59 (Distinct procedural service) but there are bundles you need to watch with 29822 and it may be difficult to earn your payment. You may report diagnosis codes 726.2 (Other affections of shoulder region not elsewhere classified), 726.13 (Partial tear of rotator cuff), 726.11 (Calcifying tendinitis of shoulder), or 726.19 (Other specified disorders of bursae and tendons in shoulder region).