Orthopedic Coding Alert

Question: Encounter notes indicate that the orthopedist decided to perform a diagnostic left hip arthroscopy. During the procedure, the orthopedist noticed a few loose bodies in the surgical area, which they removed. Can I report two arthroscopy codes for this encounter?

Texas Subscriber

Answer: No you cannot report two arthroscopy codes in this case. When a diagnostic procedure turns surgical, the work for the diagnostic procedure is rolled into the work units for the surgery the orthopedist performs.

On your claim, report 29861 (Arthroscopy, hip, surgical; with removal of loose body or foreign body) for the arthroscopy with modifier LT (Left side) appended to indicate laterality.

There’s more: The hip arthroscopy code set is pretty deep. The code for diagnostic arthroscopy is 29860 (Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)). Here are the other surgical codes you might consider for your physician’s services:

• 29862 (Arthroscopy, hip, surgical; with debridement/ shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum)
• 29863 (… with synovectomy)
• 29914 (… with femoroplasty (ie, treatment of cam lesion))
• 29915 (… with acetabuloplasty (ie, treatment of pincer lesion))
• 29916 (… with labral repair).