Wiki Shoulder Scope & CCI

[caromissunc1]

In 2013, I have been coding out all of the procedures performed on the shoulder except for Medicare. I was under the impression that according to 2013 CCI that "the shoulder was considered one anatomic location" so we could only code out the most expensive procedure performed. (Rotator repair, extensive debridement, DCE we could only code out 29827 for Medicare patients).
Now I am hearing that there are peeps that are coding out all procedures performed on Medicare patients and they are getting paid.
Was I reading the CCI edits wrong? Can we still charge for everything on MCR patients? Even on Code Correct, they allow all procedures.
Have I lost a ton of money for my orthopods last year?
HELP!

 

[mitchellde]

The shoulder consists of different compartments, if the debridement is in a separate compartment then it can be billed out. If the debridement is documented as extensive, as in beyound what is ordinarly performed then it is separately billable.

 

[OCD_coder]

Jan 1, 2113, Medicare changed the rules on us for shoulders. According to Medicare the shoulder joint is one unit, there are not different compartments (See the source below).

You can only report procedures that bundle if they are performed in the contralateral shoulder, this is why you are seeing that a modifier is allowed. So if people are applying the modifier 59, they will get paid because the Op Report is not being sent in with the report and they are just turning off the edit. But this is incorrect coding by MEDICARE RULES. Many commercial carriers follow NCCI rules, for example United Healthcare and the same rules apply.

Just because someone gets paid does not mean it was reported correctly. You were following the guidelines correctly so be assured you are not losing money but protecting your practice from getting a fine if audited.

Source: CMS NCCI Coding Manual, Chapter 4, IV-15
22. CMS considers the shoulder joint to be a single anatomic structure. An NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder joint procedures should never be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder joint. This type of edit may be bypassed only if the two procedures are performed on contralateral joints.