Orthopedic Coding Alert

Question: Our surgeon submitted the following operative note, but we can't determine which ICD-9 code applies. Should we report all of them or just one? "A frayed and detached superior anterior labrum with detachment of the junction of the anterior superior and anterior portion of the labrum and about 90 percent detachment of the anterior aspect of the labrum right at the biceps tendon anchor. Some fraying of the  posterior superior labrum but no detachment, and no detachment of the biceps tendon anchor itself. Some synovitis especially anteriorly and superiorly.

New Hampshire Subscriber

Answer: If the patient suffered shoulder joint instability, you should report 718.81 (Other joint derangement, not elsewhere classified; shoulder region). If not, you should use 719.91 (Unspecified disorder of joint;  shoulder region) instead. ICD-9 does not include any specific codes for labral lesions.

Some coding experts also recommend adding the diagnosis code 718.01 (Articular cartilage disorder; shoulder region) to your claim. In addition, you can add 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) for the labral tear, because the documentation notes up to 90 percent detachment of the labrum. Ensure, however, that the documentation includes an injury date before you add this code.

Although the insurer's computer will only scan the first, main diagnosis code listed, you should list all of the codes that apply. That way, if the payer challenges a claim, you can help your appeal by having already sent the insurer all the applicable diagnoses on record for the patient.