Orthopedic Coding Alert

Question: Encounter notes indicate that after a level-three office evaluation and management (E/M) service for a new patient, the provider performed a right elbow arthroscopy with synovectomy. Final diagnosis was transient synovitis. I’m having trouble settling on a CPT^® code because it lists two for these types of arthroscopies. What is the difference between a partial and complete synovectomy?

Texas Subscriber

Answer: You should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M with M67.321 Transient synovitis, right elbow appended to indicate the patient’s synovitis. Also, append modifier 57 (Decision for surgery) to indicate that the E/M was a significant, separately identifiable service from the arthroscopy.

As for the arthroscopy, the devil’s in the details of the synovectomy. If notes indicate that the provider removed only portions of the synovium, report 29835 for the surgery. If notes indicate that the provider removed the entire synovium, report 29836.

Either way: You should append modifier RT (Right side) to 29835 (Arthroscopy, elbow, surgical; synovectomy, partial) or 29836 (… synovectomy, complete) to indicate laterality.