A Reach Above the Rest: Arthroscopic Shoulder Surgery
Shoulder surgery has been revolutionized through arthroscopic equipment.
By Annette Grady, CPC, CPC-H, CPC-P, CCS-P
When dealing with the shoulder, the list of potential medical problems is as long as your arm. In this world of hustle and bustle, shoulders carry our life’s necessities: laptops, briefcases, handbags, babies, grocery bags, only to make us wonder later why we hurt. These habits have left us vulnerable to upper extremity pain, stress and injury.
Shoulder surgery has revolutionized over the past 10 years with the majority of today’s surgeries performed primarily through arthroscopic equipment. This presents dilemmas when choosing CPT® codes, as technology is always ahead of the coding process.
Current procedures have the specific intent of addressing certain pathophysiology, and understanding the medical necessity behind the procedures can help in choosing a CPT® procedure code. To clarify the medical necessity for shoulder repair, let’s first take a look at shoulder diseases and ailments.
The shoulder is highly mobile and relatively unstable, so it’s a primary source for ailments. The bones provide little inherent stability to the joint, and it relies on the surrounding tissues, such as capsule ligaments and the rotator cuff muscles to hold the ball in place. The bones of the shoulder are held in place by muscles, tendons and ligaments. This allows the shoulder to injure easily. The other primary source of ailments is the natural aging process of wear and tear, which can accelerate when the shoulder is overused.
The types of disorders that are diagnosed with arthroscopy include tears, swelling, abnormal formations, detachments, loose fragments (loose bodies) and arthritis. We’ll explore these disorders and review the proper coding for shoulder repair.
29806 Arthroscopy, shoulder, surgical; capsulorrhaphy
Most cases of recurrent shoulder instability or dislocation are associated with a Bankart lesion. A common orthopedic eponym, a Bankart lesion is the detachment of the fibro-cartilaginous edge of the shoulder socket (glenoid labrum) from the bony socket (the glenoid). The procedure described by code 29806 includes mobilization of the glenoid labrum (Bankart lesion) and shoulder ligaments, as well as the following services:
- Preparation of the glenoid’s edge by inserting drill holes for bone anchor placement. Passage of sutures through the labrum and the glenohumeral ligaments.
- Insertion of anchors into the glenoid, and repair of the glenoid labrum and the glenohumeral ligaments to the edge of the glenoid.
Another term you may see in the operative note is “plication.” Note: code 29807 is considered an integral portion of this procedure unless the SLAP lesion is identified as Type II or Type IV.
29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion
A SLAP lesion is a superior labrum-anterior posterior tear, or upper rim front-back. There are various types of SLAP lesions, but the most common are Type I thru Type IV.
SLAP Type 1: This is a partial tear of the labrum, where the edges are rough, but not completely detached. Arthroscopic treatment is usually debridement of the edges, 29822.
SLAP Type 2: Type 2 is the most common type of SLAP tear. The labrum is completely torn off the bone, due to an injury (often a shoulder dislocation). Arthroscopic treatment is repair of the tear, 29807.
SLAP Type 3: A type 3 tear is a ”bucket-handle” tear of the labrum, where the torn labrum hangs into the joint and causes symptoms of “locking” and “popping” or “clunking.” Arthroscopic treatment is a repair or debridement of tear, 29822 or 29807.
SLAP Type 4: The type 4 SLAP tear is one where the tear of the labrum extends into the long head of the biceps tendon. Arthroscopic treatment is the repair of the tear and repair of the biceps tendon or tenodesis, 29807 and 29999 or (S2114 for those payers that recognize HCPCS “S” codes).
29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body
A number of conditions can cause fragment of cartilage or bone to come loose and float around in the joint. Among these causes are shoulder injuries and arthritic conditions. The removal of loose bodies or foreign bodies procedure is usually considered an integral part of most shoulder arthroscopy procedures. It may be coded separately, unless the documentation supports that the loose body is greater than 5mm, or if the loose body was removed through a separate incision..
29820 Arthroscopy, shoulder, surgical; synovectomy, partial
29821 synovectomy, complete
In patients with rheumatoid arthritis, the synovium surrounding the shoulder joint may become inflamed, causing pain and stiffness. If the bones in the shoulder joint are not damaged, a synovectomy can be performed to restore motion and reduce pain.
29822 Arthroscopy, shoulder, surgical; debridement, limited
29823 debridement, extensive
A range of injuries and degenerative conditions can indicate the need for arthroscopic debridement. Debridement involves loose debris removal or irregularities within the joint. Generally, the following conditions can be treated with debridement:
- Early osteoarthritis
- Torn or unstable intra-articular structures
- Removal of loose or foreign bodies from the joint
29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
Acromioclavicular (AC) joint symptoms are common in shoulder disorders, resulting from both direct injury to the AC joint and rotator cuff/impingement phenomenon with AC arthrosis. Once the AC joint is exposed, a burr is introduced from an anterior inferior AC portal and is directed from anterior to posterior and inferior to superior, resecting approximately 1 to 1.5 cm of clavicle. Documentation in the operative note should support the amount of bone resected.
29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release
This is done for subacromial impingement, as part of an ACJ excision and as part of a rotator cuff repair. First, the coraco-acromial ligament (CA ligament) is shaved from the acromion. Then, the bony acromial spur is shaved away with the arthroscopic shaver.
This procedure is often bundled under Medicare CCI edits, but the American Academy of Orthopaedic Surgeons (AAOS) states that it should be coded separately. Adjust your coding according to the payer.
29827 Arthroscopy, shoulder, surgical; with rotator cuff repair
The rotator cuff muscles consist of the “SITS” muscles: supraspinatus superiorly, infraspinatus and teres minor posteriorly and subscapularis anteriorly. These muscles are responsible for the stability and the normal mechanics of the shoulder joint. Damage to these muscles can result in impingement syndrome and/or instability of the joint. A rotator cuff repair involves stitching to attach the torn tendon to the arm bone (humerus) using sutures and bone anchors. Arthroscopic repair requires more technical skills than open repair.
Key Coding Issues
There are various CCI edits surrounding this code. Medicare CCI edits include the anterior capsulorrhaphy (29806) and limited debridement, (29822) as part of the rotator cuff tear repair. The AAOS’s Complete Global Service Data does not include these edits and AAOS says that they may be coded separately.
Biceps tenodesis is reported with 29999 Unlisted procedure arthroscopy. During this procedure, the long head of the biceps tendon is detached, and then reattached to the humerus bone below the shoulder. This procedure is more complex than a tenotomy, but avoids the risks of biceps discomfort, weakness and a “popeye” appearance. The procedure involves releasing the long head biceps (LHB) tendon, and then attaching it back to the humerus bone with a screw. This is an unlisted CPT® procedure, but for those payers that recognize HCPCS S codes, S2114 is applicable.
Tip: Understanding the condition oftentimes will direct you to the correct code choice.