Orthopedic Coding Alert

Acute or chronic? A $60 difference is at stake.

If youre not pinpointing where the orthopedic surgeon began a shoulder surgery, you could be overlooking separately reportable pre-repair procedures.

Take a swing at the following real-life shoulder situation to see how your coding skills fare.

Scenario: A 61-year-old general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem.The orthopedists physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear. The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.

How should you report this?

Identify Initial Procedures

First, lets look at two portions: the labral debridement and the rotator cuff.

A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. You should begin with 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), although youll need to append a modifier when you add other codes.

Secondly, you should then address the open rotator cuff repair, using 23412 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic).

Important: If you choose 23410 (... acute) instead of chronic code 23412, you will gain about $60 more reimbursement for this part of the surgery, but acute is not appropriate in this case. Hes been having this pain for over six months, Stout says. Acute describes pain that began more recently, certainly within the past six months.

Apply Modifiers to Subacromial Decompression

For the subacromial decompression, you should turn to arthroscopy codes. The next codes on your claim should be 29824-51 (... distal claviculectomy including distal articular surface [Mumford procedure]; Multiple procedures) and 29826-59 (... decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; Distinct procedural service).

Why modifier 51 and 59? The Correct Coding Initiative (CCI) bundles 29826 into 23412, but you can override that edit in this case with modifier 59. CCI does not bundle 29824 with 23412, so you dont need modifier 59 to override that edit. You may need modifier 51 to indicate multiple procedures.

After all, you dont want to use modifier 59 unless you have to, Stout says. Keep in mind that some payerssoftware, such as Medicares Outpatient Code Editor, automatically applies modifier 51 for multiple procedure claims. Ask your payers whether you need to use this modifier.

Pull Your Codes Together

Your final codes should look like this:

" 23412 for the open rotator cuff repair

" 29826-59 for the arthroscopic acromioplasty

" 29824-51 for the arthroscopic distal clavicle excision

" 29823-59 for the arthroscopic extensive debridement.