Orthopedic Coding Alert

Procedure and documentation could add RVUs to your claim.

Your orthopedist completes an arthroscopic Bankart repair and instructs you to report both 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29807 (... repair of SLAP lesion). National  Correct Coding Initiative (CCI) edits bundle 29806 and 29807, although CCI notes state that you can include a modifier to differentiate the services and code both services.

Does your surgeon's documentation or service merit separate reporting? Follow our experts' advice to determine whether his recommendation is on track. Know the Pitfalls of Submitting Both Codes

A Bankart lesion (718.31, Recurrent dislocation of joint; shoulder region) occurs when the patient tears the labrum at its attachment to the inferior glenohumeral ligament. The injury usually occurs when the patient sustains a shoulder dislocation.

The arthroscopic procedure usually requires a repair of the labral injury, William J. Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C. The extent of labral injury guides your code selection.

Inferior injury: CPT does not include a specific arthroscopic code for an inferior labral injury. You'll report 29806 for capsulorrhaphy. If the surgeon completes 29806 only via the labral repair (tightening up the antero-inferior gleno-humeral ligament), Mallon says you cannot legitimately report any other code.

Extensive injury: If the surgeon documents that the labral injury extends into the anterosuperior quadrant of the gleno-humeral joint, your coding changes. Submit 29807 for repair of the labrum.

Extra procedure: Many surgeons add a tightening of the capsule, termed a "rotator interval closure," Mallon says. "This procedure is completely independent of the labral repair and implies that the surgeon did greater work," he says. "If it is documented well, you could code both 29806 and 29807 --��" but your payer might still not allow both codes."

Enjoy a Bottom Line Boost When Applicable

"While CCI currently bundles a SLAP repair with a Bankart repair, the AAOS Complete Global Service Data for Orthopaedic Surgery (GSD) does not," points out Judy Larson, CPC, billing manager for Rockford Orthopedic in Rockford, Ill. The GSD and CCI edit notes each instruct coders to append modifier 59 (Distinct procedural service) to 29807 when the surgeon's documentation supports two separate, distinct procedures. For example, the surgeon should document that he completed capsulorraphy and labral repair separately and in different sections of the joint (usually one superior and one inferior).

Precert: "As usual, when reporting these two codes together you might want to verify things with the insurance payer prior to surgery," Larson advises. Legitimately reporting both 29806 and 29807 can lead to a healthier bottom line.

According to the 2010 Medicare Physician Fee Schedule, 29806 carries 27.89 total relative value units (RVUs) and a nationally adjusted fee of $791.71 for facility or non-facility procedures (based on the national conversion factor of 28.3868). Code 29807 carries 27.16 total RVUs and a nationally adjusted facility or non-facility fee of $770.99. The insurer might not reimburse the fully allowed amount for 29807, but experts recommend that you still report both 29806 and 29807 when you have sufficient documentation.