Orthopedic Coding Alert

Question: Notes indicate that the surgeon performed a level-four evaluation and management (E/M) service for an established patient with shoulder instability. She diagnoses a SLAP (superior labral tear from anterior to posterior) lesion, and schedules surgery for the patient. The next day, the surgeon performs a SLAP lesion repair on the patient’s left shoulder. How should I code this encounter?

Minnesota Subscriber

Answer: We’ll discuss the surgical coding first, then E/M coding, and then modifiers needed to complete this claim.

Surgery coding: For the SLAP repair, report 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion).

E/M coding: You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) for the E/M service that preceded the surgery.

Modifiers: Be sure to append modifier LT (Left Side) to the lesion repair code, if the payer requires the modifier. Also, append modifier 57 (Decision for Surgery) to 99214 to show that a major surgery followed this E/M.