Outpatient Facility Coding Alert

Question: The surgeon documented arthroscopic biceps tenodesis along with arthroscopic extensive debridement including posterior capsular release and debridement and lysis of subacromial postoperative adhesions. What codes should I use to cover the entire procedure?

Alabama Subscriber

Answer: For arthroscopic biceps tenodesis you should submit 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis). Code 29825 (...with lysis and resection of adhesions, with or without manipulation) would cover the posterior capsular release, debridement, and lysis of subacromial postoperative adhesions.

Remember: Surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy, but you don’t usually report a diagnostic code with a surgical code. Nonetheless, there are situations when you can submit both the codes.

Example: If the physician schedules an arthroscopic subacromial decompression (29826, ... decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e., arch] release, when performed [List separately in addition to code for primary procedure]) and an open rotator cuff repair (23412, Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic) during the same operative session, you should then bill both codes. However, the physician should justify the reasons for the separate approaches in his operative notes.

If the physician schedules only an arthroscopic procedure, such as 29826, and then decides to do an open procedure mid–surgery, you would report only the open procedure code.

If the physician performs a diagnostic arthroscopy and discovers he must perform an open repair of a previously unknown condition, you can report both the open repair code and the diagnostic arthroscopy code by appending the 59 modifier (Distinct procedural service) to the diagnostic arthroscopy.