Orthopedic Coding Alert

Question: The diagnosis reported by our surgeon includes the following:

1.   Right hip pincer-type femoral acetabular impingement

2.   Anterior superior acetabular labral tear

3.   Focal segment of Grade 4 chondral delamination

4.   Iliopsoas bursitis

The procedures documented include the following:

1.   Right hip arthroscopic labral repair including osteoplasty, acetabular rim trim, labral takedown, and re-fixation and chondroplasty of the acetabular rim.

2.   Iliopsoas release, arthroscopic.

Please help us with the correct coding to report these procedures.

Alaska Subscriber

Answer: You should report 29916 (Arthroscopy, hip, surgical; with labral repair) for the arthroscopic labral repair of the hip. As per CPT^®, you do not report 29862 (Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage [chondroplasty], abrasion arthroplasty, and/or resection of labrum]), 29863 (Arthroscopy, hip, surgical; with synovectomy), and 29915 (Arthroscopy, hip, surgical; with acetabuloplasty [i.e., treatment of pincer lesion]) in addition to code 29916. There is no code for arthroscopic iliopsoas release and 29999 (Unlisted procedure, arthroscopy) seems to be the best choice.

Erratum: The section ‘You may report both 29806 and 29807 when you have sufficient documentation. CCI bundles a SLAP repair with a Bankart repair According to CCI, Code 29807 is a column 2 code for 29806, but a modifier is allowed in order to differentiate between the services provided. You append modifier 59 to 29807 when the surgeon’s documentation supports two separate, distinct procedures.’ in answer to “Reader Question: Be Vigilant About Documentation for 29806, 29807” published in Orthopedic Coding Alert, Vol.16 No.2, should read as follows: