Orthopedic Coding Alert
Bundle Biopsy Into Arthrotomy
Question: Encounter notes indicate that the orthopedic surgeon performed a right shoulder arthrotomy with biopsy. What code(s) represent this surgery? Can I report the biopsy separately from the arthrotomy? AAPC Forum Subscriber Answer: No, you cannot report the biopsy separately. CPT® code descriptors for this procedure all read “including biopsy” or “with or without biopsy,” so there’s no opportunity to code biopsy separately. You will, however, need some more information on the arthrotomy specifics. Do this: Go back and check the notes, and try to find out which joint the surgeon treated: glenohumeral, acromioclavicular, or sternoclavicular. Then, choose from one of the following codes for the arthrotomy: Also, append modifier RT (Right side) to the arthrotomy code to indicate laterality. 
Related Articles
Orthopedic Coding Alert
- Surgery:
Remember to Code for All Services Surrounding Radial/Ulnar Fx
Also, keep several modifiers handy to separate services. When a patient reports with an ulnar/radial [...] - Modifier Madness:
Use This Guide to Answer Surgical Modifier Questions
Surgical care only? Use this modifier. When your surgeon provides fracture care, there are opportunities [...] - Surgery:
Don’t Miss Out: Code Disc Removals Separately
Also, these procedures could include other codeable services. In last month’s issue of Orthopedic Coding [...] - You Be the Coder:
Note Spinal Area on Schmorl’s Nodes Dx
Question: What are Schmorl’s nodes, and how do I choose a diagnosis code for the condition? [...] - Reader Questions:
Count Segments, Then Code Arthrodesis
Question: Encounter notes indicate that on Monday, the surgeon provided a level-four evaluation and management (E/M) [...] - Reader Questions:
Bundle Biopsy Into Arthrotomy
Question: Encounter notes indicate that the orthopedic surgeon performed a right shoulder arthrotomy with biopsy. What [...] - Reader Questions:
Leave Incident-To to the Side for This Patient Type
Question: A new patient came in and the nurse practitioner (NP) took the initial history and [...] - Reader Questions:
Final CF Doesn’t Change Much
Question: I remember that the Medicare Physician Fee Schedule (MPFS) final rule came out in November. [...] - Reader Questions:
Count Foot, Toe X-Rays Separately
Question: Encounter notes indicate that the provider performed a two-view foot X-ray and a two-view toe [...] - Reader Questions:
Descriptor Exceptions Exist for Talus Removals
Question: Do I document craterization of the talus and of the medial cuneiform with 28120? And [...]
