Orthopedic Coding Alert

Question: Which CPT code should I report for this physician's note? He documented: Left shoulder subacromial decompression, bursectomy and partial A/C joint resection. Anterior acromionectomy performed and osteotomy and subacromial decompression with bursectomy. Underside of A/C joint was resected likewise.

Florida Subscriber

Answer: First you should verify with the surgeon whether the procedures were open or arthroscopic. You cannot submit a claim until you know for sure.

For an arthroscopic subacromial decompression (SAD), you should report 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release).

For an open procedure, you could use 23415 (Coracoacromial ligament release, with or without acromioplasty) or 23130 (Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release) for a partial procedure.

The above codes cover the acromionectomy and the subacromial decompression.

For an open distal clavicle excision, you should report 23120 (Claviculectomy; partial).

If the approach is arthroscopic, submit 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure]).

You can't code further resection of the AC joint's undersection (actually the distal clavicle) with the complete distal clavicle excision.