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April 2004 Bulletin
Accurately code shoulder procedures
New codes for arthroscopic procedures may be confusing
By Robert H. Haralson III, MD, MBA, Richard Friedman, MD, and Margie Scalley Vaught, CPC, CCS-P, ACS-OR, MCS-P
There has been confusion about how to code shoulder procedures, especially relating to arthroscopic procedures. In the last few years, a number of new arthroscopic shoulder CPT codes have been added. However, some aspects of the CPT coding system itself remain confusing, a problem the AAOS CPT Committee is attempting to rectify. Until the matter is resolved, here are some suggestions on how to code shoulder procedures.
Diagnostic arthroscopy
As with all arthroscopic procedures, code 29805 (Arthroscopy, shoulder, diagnostic with or without synovial biopsy) is reported only when nothing else is done. If any other code is used, it is not appropriate to report the diagnostic code, even if the diagnostic arthro- scopy is followed by an open procedure. If an arthroscopic procedure is followed by an open procedure, the diagnostic procedure cannot be used and only the code for the open procedure can be reported.
Rotator cuff repair
Open rotator cuff repair is confusing because three codes can be used: 23410 (Repair of musculotendinous cuff, acute), 23412 (Repair of musculotendinous cuff, chronic) and 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]).
There are no standardized definitions to distinguish acute from chronic. What often makes the difference is the size of the lesion (i.e., how many tendons are involved or whether the lesion is less than 1 cm, 1 cm to 3 cm, 3 cm to 5 cm or more than 5 cm), as well as the amount of retraction and scarring, not how long ago the tear occurred.
Code 23410 should be reserved for young patients who have an acute episode resulting in a torn rotator cuff and early repair. Code 23412 is more appropriately used for most of the rotator cuff tears that occur in older individuals who have sustained a tear over time, with or without a superimposed acute episode.
If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of code 23420. If fascia or synthetic material is required, code 23420 also is appropriate. If a tendon transfer was performed, code 23397-59 would be used in addition to code 23420.
Arthroscopic rotator cuff repair is code 29827 (Arthroscopy, shoulder, surgical, with rotator cuff repair). If arthroscopic subacromial decompression with or without acromioplasty and/or coraco-acromial ligament release also is performed, code 29826-51 is appropriate. If arthroscopic subacromial decompression is done, followed by an open or mini-open rotator cuff repair, the coding sequence should be 23410 or 23412 and 29826-59.
Acromionectomy and distal clavicle excision
The AAOS Complete Guide to Global Services Data 2002 (GSD) included acromionectomy in all open rotator cuff repairs. However, acromionectomy is not included in arthroscopic rotator cuff repairs, nor is distal clavicle resection included in any rotator cuff repairs. Because many surgeons are doing arthroscopic subacromial decompressions and acromionectomies, followed by mini-open rotator cuff repairs, the AAOS CPT and ICD coding committee decided to exclude acromionectomies in all rotator cuff repairs to be consistent.
Accordingly, the 2004 GSD continues to exclude acromionectomy in open rotator cuff repairs. It is appropriate to code separately for an acromionectomy that is performed in conjunction with an open or arthroscopic rotator cuff repair. However, this cannot be done with code 23240 where the descriptor states, “includes acromionectomy.” Remember that either modifier -51 (multiple procedures) or -59 (distinct procedure) should be appended to the additional procedures, based on carrier issues.
It also is appropriate to code separately for excision of the distal clavicle, if this is done in either an open or arthroscopic procedure. This means excision of the entire distal clavicle (approximately 1 cm), not merely shaving off osteophytes at the acromioclavicular joint. The code for the open procedure is 23120; use 29824 for an arthroscopic procedure.
Procedures to correct instability
Instability is usually caused by either a defect at the insertion of the capsule into the rim of the glenoid (Bankhart lesion) or a generally loose capsule. The procedure to correct the instability depends on the cause. In addition, occasionally both a Bankhart lesion and a redundant capsule are seen in the same shoulder. The Bankhart lesion can be posterior or inferior but is usually in the anterior/inferior position of the glenoid.
There are a number of ways to address instability. The most common way to address the Bankhart lesion is to repair the capsule to the glenoid by using either sutures or staples. If the capsule is loose, adjunctive thermal capsulorrhaphy or another form of capsular reefing is done. Closure of the rotator interval is one form of capsular reefing. Other procedures, such as the Putti-Platt or other muscular or capsular transfers that are designed to limit external rotation, are done less commonly now that surgeons have a better understanding of shoulder mechanics.
For recalcitrant problems, some form of bone block procedure such as the Bristow can be done, either anteriorly or posteriorly. If a capsular-tightening procedure is required, capsular shifts, sometimes supplemented with thermal capsulorrhaphy, are done.
Specific codes are used with both the Putti-Platt or Magnuson (23450, “Capsulorrhaphy, anterior, Putti-Plat procedure of Magnuson type operation”) and the Bankhart repair with labral repair (23455, “Bankhart procedure or other similar repair of the capsule directly to the glenoid rim”). Similarly, there are specific codes for an anterior bone block (23460), for posterior bone block (23465) and for coracoid process transfer (23642). Any of the capsular shift procedures and capsulorrhaphy procedures for multidirectional instability is coded 23466. If thermal capsulorrhaphy is used for augmentation, 29999-51 should be coded.
Coding for thermal capsulorrhaphy can sometimes be confusing. There is no code for thermal capsulorrhaphy. If it is the only procedure performed, use code 29999 (Unlisted procedure, arthroscopy). This procedure is performed for instability and if it is used as an adjunct to other capsular procedures, coding 29999-51 is appropriate.
Sometimes the rotator interval is closed to address instability. If this is the only procedure done, use code 29806 (Arthroscopy, shoulder, surgical, capsulorrhaphy). If other capsulorrhaphy procedures are performed to address the instability, the rotator cuff interval closure is included in the capsulorrhaphy and should not be coded separately. It is inappropriate to report a rotator interval closure with a rotator cuff repair.
SLAP Lesions
There are several ways to code repairs of SLAP lesions. Which code to use depends on the type of SLAP lesion and what was done. Repair (debridement) of a type I SLAP lesion is always coded as 29822 (Arthroscopic debridement, limited). Repairs of types II and IV SLAP lesions are coded 29807 (Repair SLAP lesion) because an actual repair is performed.
Type III SLAP lesions are bucket-handle tears and can be either debrided or repaired; use 29822 or 29807, whichever is appropriate. Adding code 29806 (Arthroscopy, shoulder, surgical, capsulorrhaphy) for repair of a SLAP lesion is never appropriate unless there is a capsular defect in an area different than the SLAP. This is one of the most common coding errors. Even if a staple or other device goes through the capsule to repair the SLAP, capsulorrhaphy should not be coded separately.
Manipulation
Manipulation of the shoulder joint is coded only if it is the only procedure performed. If anything else is done, such as lysis of adhesion, synovectomy or debridement, coding for the other procedure includes manipulation of the joint. This agrees with the Correct Coding Initiative.
Synovectomy vs. debridement
There is nothing in CPT that distinguishes between synovectomy and debridement, although there are codes for both. In general, we suggest that debridement be reserved for situations in which articular cartilage is debrided and that the synovectomy codes be used when only soft tissue is removed. A partial synovectomy (29820) or limited debridement (29822) would consist of work done in just a portion of the shoulder, such as the front or the back of the shoulder. To support a complete synovectomy (29821) or extensive debridement (29823), the documentation should support work in BOTH the front and back of the shoulder.
Removal of loose body/bodies is included in the synovectomy and debridement codes unless the loose or foreign body is large enough to require a separate incision to remove it. The wording in the GSD is “arthroscopic removal of loose or foreign bodies greater than 5mm and/or through a separate incision.”
Coding shoulder procedures is not difficult when one understands the anatomy and follows the adage that if the work is done, it should be reported. If work is not done, it should not be reported.
