Wiki Shoulder Surgery Experts please help

[kandekane8]

Hi,

Does the following dictation justify coding 29807 with 29806? Help!

PROCEDURE:
1.Anterior labral repair with capsulorrhaphy
2.Posterior labral repair with capsulorrhaphy
3.Type 2 SLAP labral repair

During the diagnostic arthroscopy we could see that the labrum was torn anteriorly; it was off from the attachment of the superior
glenohumeral ligament at the bicep anchor all the way down around the back anteriorly as well including a posterior labral tear and a type 2 SLAP tear. Anteriory, the labrum was scarred down over the neck. The bicep tendon was intact. Subscapularis was intact. The articular surface of the undersurface of the rotator cuff was also intact with some slight fraying. There was a very small Hill-Sachs lesion Otherwise, cartilage surfaces well preserved. There
was a positive drive-through sign. At this pont we then proceeded to liberate the labrum using a Freer liberating it up from front all the way up to the bicep anchor and then preparing the glenoid both anteriorly and posteriorly with both a shaver curet and then underneath the bicep used the shaver as well as a curet to good bleeding bone. I initially placed two #2 Ortho cords horizontal matress near the posterior root of the bicep and then a simple posterior to this. These were then tagged outside the cannula, left for later repair. I then proceeded to pass sutures low anterior inferior and posterior inferior and working my way up both the anterior and posterior aspects of the glenoid using a #2 Ortho Cord in cinch stitch type fashion and placing a total of 3 anterior and 3 posterior 2.9mm Pushlocks, followed by an additional 2 for the prior sutures for the repair the SLAP lesion. This gave good approximation with bumper and centralization of the humeral head. All instruments were removed. All sponge and needle counts were correct.

 

[OCD_coder]

Not when they are performed on the same shoulder joint, they are bundled and the documentation does not meet the necessary requirements to apply a modifier to override the NCCI edit.

 

[Orthocoderpgu]

I had this very same scenario just two weeks ago. In reading the OP note, it sounded like all the physician did was the SLAP. But in speaking with him, he didn't. And the capsulorrphy's were done outside of the SLAP area (11-2). Had he documented the clocking positions of the two repairs, I could have given it to him. He said he was going to update the documentation but he never did. I agree. Unless your given the clocking positions, it's not enough to add the modifier and get by the edit. The insuance will request the op note, and your note will not support all three codes.

 

[OCD_coder]

Orthopedic Pink Sheets

Year: 2004

Issue: March 01

Title: The verdict is in: Bill 29806 for scope Bankarts

Subtype: Orthopedic


Body:
The verdict is in: Bill 29806 for scope Bankarts

After months of discussion and review, the AmericanAcademy of Orthopedic Surgeons (AAOS) and CPT are now pulling in tandem: Both say to use 29806 for an arthroscopic Bankart. And, they agree it?s OK to bill 29807 with 29806 under certain circumstances.
You weren?t alone if you found yourself scratching your head when CPT 2004 came out last November. At that time, the AMA directed coders to use 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy) for an arthroscopic Bankart ? even though they had told you to use new code 29807 (repair SLAP lesion) in these cases just a year earlier. The change in 2004 was interpreted by many as a signal to orthopedic practices that they could now bill both codes when a SLAP lesion repair is done during capsulorrhaphy for a capsular defect.

(Note: You still use 23455, capsulorrhaphy, anterior; with labral repair [eg, Bankart procedure], for open procedures.)

You won?t get the full fee schedule amount for both procedures because the codes fall under multiple endoscopy reimbursement rules ? but the deduction will equal only about $400 so you still come out significantly ahead.

But proceed with caution, warns Robert Haralson, MD, AAOS coding committee chair. ?In order for you to bill both codes [29806 and 29807], there must be two distinctly separate lesions, a SLAP tear and a capsular defect,? he says. In other words, you can?t bill both if you correct both problems in the same region of injury. ?For instance, sometimes there is a small capsular defect at the area of the SLAP and the staple goes through the capsule to repair the SLAP. Double billing in a case like this would be inappropriate.?
National Correct Coding Edits (CCI) version 10.0, which went into effect January 1, 2004 , bundles 29807 with 29806. But it carries an indicator of ?1? which means you can bypass the edit with an appropriate modifier like -59 (distinct procedural service). Similarly, the AAOS? Complete Global Service Data Orthopaedic Surgery (2003) does not list 29807 as included in the surgical package for 29806 ? seemingly indicating you bill each code separately.

Just make sure the surgeon?s documentation truly supports that separate lesions were repaired ? and don?t use the -59 simply to ensure reimbursement. ?Keep in mind that modifiers were created specifically to let payers know that you?re not following ?normal? coding rules because of unusual circumstances,? warns Carol Pohlig, BSN, RN, CPC, who works in the Department of Medicine at the Hospital of the University of Pennsylvania . Because they address exceptions and not the rule, the potential misuse or abuse is significant. ?It?s easy to slip into the habit of using modifiers simply to get around denials,? she admits. ?But that?s not right.?

Melody Mulaik, MSHS, CPC, RCC, president, Coding Strategies, Atlanta , Ga , agrees, recounting a horror story one client told her. ?One practice I worked at had a large percentage of denied claims that were subsequently paid. I asked one of the office staff how this came to be. She told me that when a claim was denied, she simply added modifier -59 and it got paid. That?s not how it works ? and this sort of approach is definitely abuse.? ~ Elizabeth Glaser