Orthopedic Coding Alert

Question: Encounter notes indicate that the surgeon performed a level-four office evaluation and management (E/M) service for an established patient with post-traumatic osteoarthritis of the right shoulder. Then, they performed acromionectomy with a coracoacromial ligament release. How should I code this encounter, and what is acromionectomy?

Missouri Subscriber

Answer: On this claim, you should report:

• 23130 (Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release) for the acromionectomy
• Modifier RT (Right side) appended to 23130 to indicate laterality
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99214 to show that the E/M led the provider to consider the surgery
• M19.111 (Post-traumatic osteoarthritis, right shoulder) appended to 23130 and 99214 to represent the patient’s injuries

More on the surgery: During acromionectomy, which is also called an acromioplasty, the provider reshapes the acromion, the bony projection at the end of the shoulder blade, to restore motion to the shoulder and protect the rotator cuff. They may partially remove the acromion and/or incise the ligament that attaches the muscle the shoulder blade.