Orthopedic Coding Alert

When an arthroscopic procedure and an open procedure (arthrotomy) are done during the same operating room session, payers often see as bundled what physicians and coders see as separate. The coder who understands the perspective of the payer will be able to make the physicians case for genuinely separate procedures.

There has been a CPT code for the arthroscopic procedure since 1990. Code 29826 (arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) applies. Coding for just the decompression is no real problem.

A coders woes begin when more than the decompression takes place during an operating room session. Dawn McDonald, who does coding and billing for an orthopedic group in Texas that does many subacromial decompression procedures, says, We usually dont have a lot of trouble with the code, unless we also do an unlisted procedure like a rotator cuff or a bursectomy.

Kathy Lee, a coder for The Center for Neurosciences, Orthopaedics & Spine in Sioux City, Iowa, agrees with McDonald. Lee points to arthroscopic shoulder decompression done during the same operating room session as a procedure such as an open partial claviculectomy (23120) as causing the only difficulties.

Note: For more about the shoulder and the perils of substituting codes, see Avoid SLAP and Bankart Repair Denials: Dont Substitute Codes on page 73 of the October 1999 Orthopedic Coding Alert.

Avoid Problems with Payers

There are five simple ways to avoid denials of shoulder decompression reimbursement claims:

1. Do not code for a diagnostic arthroscopy: Both McDonald and Lee point out that 29826 includes the diagnostic arthroscopy, and it cannot be billed separately. Lee emphasizes, We never bill for the diagnostic scope that precedes the procedure. Hence, we have no problems. In any case, its inappropriate to do so.

2. Use modifier -59 when appropriate: If the decompression procedure is done along with an unlisted procedure such as an arthroscopic rotator cuff repair, it might be possible to bill for both using modifier -59 (distinct procedural service) on the second procedure. To succeed with the appending of modifier -59, the two procedures would have to be done for different reasons. If they are done through the same portals, payers will most likely not reimburse for two procedures.

3. Use modifier -51 when appropriate: If the procedure is done in conjunction with an unrelated open procedure, it might be possible to bill for both using modifier -51 (multiple procedures). But this will be impossible to justify to the satisfaction of most payers under most conditions for which shoulder surgery is the remedy. See 4 below to understand why.

4. Do not code for two procedures if an open procedure supplants closed: If an orthopedic surgeon (OS) schedules an arthroscopic shoulder decompression, begins that procedure, and then opens the shoulder to do a rotator cuff repair, only the rotator cuff repair can be coded. When an arthroscopic procedure switches to an open one, only the open one can be coded.

If the physician schedules arthroscopic shoulder decompression and an open rotator cuff repair during the same operating room session, and justifies the reason for the separate approaches in writing in advance, separate payment might be possible. Payers are skeptical when certain procedures contain elements of other proceduresfor example, bone spurs might be removed from the acromion in the case of either a rotator cuff repair or a shoulder decompression.

Coding tip: An open rotator cuff repair necessitated by an acute condition is coded 23410 (repair of ruptured musculotendinous cuffe.g., rotator cuffacute). When a chronic condition is the cause, the code is 23412. There is no unique code for an arthroscopic rotator cuff repair. Use CPT 29909 (unlisted procedure, arthroscopy).

5. Insist on thorough operative reports: If there is a legitimate reason for two shoulder codes and modifier -59 or -51 applies to the situation, operative notes must support the independence of the procedures. Getting maximum reimbursement for an unlisted procedure requires detailed documentation.