Part B Insider (Multispecialty) Coding Alert

The new '+' symbol preceding 29826 makes a bigger difference than you think.

Myth: If you perform subacromial decompression alone without any other services, you can't bill for the service.

Reality: You can bill for the subacromial decompression, if you know your payer's coding rules and follow the AAOS's advice.

Background: CPT® 2012 brought changes to the way you'll report arthroscopic acromioplasties, so you'll want to ensure you're up to speed on applying code +29826 (Arthroscopy, shoulder, surgical; 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]), which is no longer a standalone code. See the advice that follows for more on how to accurately report + 29826 in addition to codes for other primary procedures this year.

Document Additional Primary Procedures

The CPT® code +29826 changed from a standalone to an add-on code in 2012, meaning that you can now report this only when your surgeon does another scope procedure as the primary procedure.

Coders have been reporting code 29999 (Unlisted procedure, arthroscopy) when only an arthroscopic subacromial decompression of the shoulder was performed.

"Originally AAOS advised use of the unlisted procedure code 29999 when performing 29826 alone. Recent clarification from AMA/CPT® is to use CPT® codes 29822 or 29823, depending upon the extent of debridement supported by the operative report," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington.

"When performing an arthroscopic acromioplasty alone, submission using the unlisted arthroscopy code of 29999 has been widely practiced," says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. "The AMA has long stood by the theory that if an appropriate code does not exist, the procedure should be submitted using the appropriate unlisted CPT® code."

This year's change means that you can now turn to 29822 (Arthroscopy, shoulder, surgical; debridement, limited) or 29823 (Arthroscopy, shoulder, surgical; debridement, extensive). "Both the AMA and AAOS have issued statements that the appropriate debridement code (29822 or 29823) should be reported when arthroscopic subacromial decompression is performed as a standalone procedure," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

The scope procedures that you may commonly encounter for primary procedures are the arthroscopic claviculectomy, arthroscopic rotator cuff repair, arthroscopic debridement (debridement unrelated to the work performed for the decompression), or arthroscopic biceps tenodesis. "The add-on code +29826 is allowed with CPT® codes 29806 -- 29825, 29827 and 29828," says Stumpf. These are listed below:

• 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy)
• 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion)
• 29819 (Arthroscopy, shoulder, surgical; with removal of loose body or foreign body)
• 29820 (Arthroscopy, shoulder, surgical; synovectomy, partial)
• 29821(Arthroscopy, shoulder, surgical; synovectomy, complete)
• 29822 (Arthroscopy, shoulder, surgical; debridement, limited)
• 29823 (Arthroscopy, shoulder, surgical; debridement, extensive)
• 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure])
• 29825 (Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation)
• 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)
• 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis)

"There is a current CCI edit disallowing use of 29826 with 29822. There has been verification from CMS that this edit is to be lifted in the CCI update for April 2012. The 29822/29826 CCI edit will be lifted retroactive to January 1, 2012. If you have been receiving denials, please hold these claims for refilling under the new edits being released in April 2012," says Stumpf.

Additional option: When your surgeon performs an arthroscopic subacromial decompression as the only procedure, you may turn to codes 29822 or 29823, depending upon whether your surgeon does a limited or extensive debridement.

However, you will need to ensure that your surgeon is aware of the significance of these codes and documents all the procedures done in detail. Do not forget to confirm with your payer the protocols or definitions that the payer is using for the arthroscopic subacromial decompression when it is the only procedure performed. "There is uncertainty for 29822 when attempted to be billed with 29826. Private payers may deny it though Medicare is likely to allow it," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

"According to the AMA, one should report code 29822 or 29823 when arthroscopic subacromial decompression is performed either as a solo procedure or in conjunction with other procedures that are not parent codes," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Apply These Rules When Reporting Open Procedures

You shouldn't report code +29826 as add-on code with codes for open rotator cuff repair, 23410 (Repair of ruptured musculotendinous cuff [eg, rotator cuff] open; acute) or 23412 (Repair of ruptured musculotendinous cuff [eg, rotator cuff] open; chronic).

"In this case, you turn to 29822 or 29823 for arthroscopic subacromial decompression," says Stout. You will need to check with your payer and confirm if you can report these codes with modifier 22 (Increased Procedural Services......). "There is no cross over for use of the new add-on code 29826 with open codes," says Stumpf. "Per AAOS Now CPT® Code Update 2012 -- Part 1, the recommendations are to use the 22 modifier in addition to CPT® codes 23410 and 23412 or to report 29822 or 29823 (limited or extensive debridement) based on the documentation. This would be a care center, provider and/or perhaps a carrier driven choice," she advises.

Your surgeon, as a common practice, may be doing an arthroscopic acromioplasty with open procedures. "Many of our providers perform an arthroscopic decompression with an open distal clavicle excision," says O'Brochta-Woodward.

The billing together for procedures like arthroscopic decompression and open distal clavicle excision in CCI has been an area of concern to coders. "These two procedures have never been considered bundled in CCI. With the current coding nomenclature, an arthroscopic acromioplasty can no longer be billed with an open distal clavicle excision since 29826 must be billed with a primary arthroscopic procedure," says O'Brochta-Woodward. "There has been much concern in the orthopedic community, as this code relates to the performance of an arthroscopic acromioplasty in combination with an open rotator cuff repair (23410 or 23412). This code combination has always been bundled in CCI allowing for a modifier only if the procedure was performed on the opposite shoulder. Several years ago AAOS published an article promoting separate 'areas' in the shoulder (subacromial, glenohumeral and acromioclavicular) thus promoting the ability to submit procedures considered bundled in CCI with the use of the 59 (Distinct Procedural Service...) modifier. This concept however was never adopted by CMS. CMS has never recognized the separate areas of the shoulder. Thus, when submitting claims to Medicare or to other health plans that follow Medicare's rules, appending the 59 modifier was being done in error."