Don't Choose Shoulder Scope Codes Off the Cuff
Reimbursement for orthopedic surgeries under the Medicare Ambulatory Surgical Centers (ASC) payment system may be on the rise, but improper coding based on inadequate documentation can still leave your practice shouldering the burden. An article in the March issue of Outpatient Surgery Magazine offers guidance for accurately coding shoulder scopes.
Rotator Cuff Repair and Reconstruction
When it comes to rotator cuff repairs, pay close attention to wording, or lack there of. CPT® rotator cuff Repair, Revision, and/or Reconstruction codes 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute, 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic, and 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) are for acute or chronic conditions only. If you don’t see “acute” or “chronic” in the documentation, “don’t assume,” says Christina Bentin, CCS-P, CPC-H, CMA, in her article “Getting Reimbursed for Shoulder Scopes” (registration required). The condition must be documented to support the code selection.
Medicare reimbursement is the same for codes 23412 and 23420, so “base your selection on whether the surgeon repaired (23412) or reconstructed (23420) a chronic tear,” Bentin says.
Keep in mind that 23420, according to American Medical Association (AMA) guidelines, is for reconstruction of an extreme tear, typically requiring rearrangement of the normal anatomy, with occasional grafting of biological or nonbiological material. The AMA says three of the four rotator cuff muscles/tendons should be torn; however, AMA guidelines also state that you shouldn’t necessarily base your code selection on the number of tendons. In other words, “three tendons need not be torn to support reporting CPT® 23420,” says Bentin.
Use codes 23410 and 23412 to report mini open rotator cuff tear repairs, says Bentin, and remember to base your selection on whether the repair was documented as acute or chronic.
Arthroscopy, shoulder code 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair is for an arthroscopic rotator cuff repair, regardless of the condition. Still, the operative report should specify acute verses chronic as well as the technique (open vs. arthroscopic) and whether it was a repair or reconstruction.
Excision of the distal clavicle involving more than a simple shaving of osteophytes at the AC joint is reported separately whether performed open or closed, according to the American Academy of Orthopaedic Surgeons (AAOS). The operative report must indicate the distal clavicle excision size to separately report CPT® codes 23120 Claviculectomy; partial and 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure).
Note that some carriers may consider an excision of less than 1 cm inclusive to the main procedure, so always check your carrier’s policy before reporting these codes separately.
Arhtroscopic Labrum Repairs
Report CPT® 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy for surgical capsular repairs performed arthroscopically, says Bentin. However, Bentin advises, use unlisted code 29999 Unlisted procedure, arthroscopy verses S2300 for arthroscopic thermal capsulorrhaphy—pending carrier guidelines.
CPT® 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion, on the other hand, is specific for a superior labrum from anterior to posterior (SLAP) repair. “Don’t use it for labral tears that aren’t SLAP tears,” warns Bentin.
Report both 29807 and 29806, per AAOS, if the surgeon performs SLAP Type II or Type IV in addition to capsulorrhaphy for a different indication, but not before you verify your carrier’s policy on reporting these two codes during the same session. Medicare edits bundle 29807 into 29806, but allows for a modifier (ie, modifier 59 Distinct procedural service) if the surgeon performs SLAP separately and distinctly from the capsulorrhapy.
“A coder shouldn’t confuse the surgeon’s repair of the labrum by attaching it to the capsule as a separately identifiable capsulorrahaphy,” says Bentin. “The separate reporting of the capsulorrahapy is indicated when there is a capsular defect unrelated to the labrum tear.”
Arthroscopic Shoulder Debridement
CPT® 29822 Arthroscopy, shoulder, surgical; debridement, limited covers limited debridement of soft or hard tissue, says Bentin. Use it for limited labral debridement, cuff debridement, or the removal of osteophytes and degenerative cartilage. Save CPT® 29823 Arthroscopy, shoulder, surgical; debridement, extensive for extensive debridement of soft or hard tissue. And, as always, documentation should support its use with a description of all areas, sites, tendons, and lesions debrided or excised.
Registered members of Outpatient Surgery can read the full article on the magazine’s Web site.