Update Your Understanding of Shoulder Arthroscopy Codes

Update Your Understanding of Shoulder Arthroscopy Codes

Anatomy is important when applying bundling rules to procedures.

The shoulder is a complex joint, and proper coding for shoulder procedures requires a strong foundation of knowledge in anatomy and physiology. Shoulder arthroscopy codes particularly can be confusing as the guidelines for arthroscopic shoulder surgeries have changed considerably in the last decade. Here are some essential points to understand about arthroscopic shoulder surgery coding and documentation.

Shoulder Anatomy

Three areas generally recognized as part of the shoulder are the:

  1. Glenohumeral joint,
  2. Acromioclavicular joint, and
  3. Subacromial bursal space.

The Centers for Medicare & Medicaid Services (CMS), however, considers the shoulder to be a single anatomic structure. This means you may not use a modifier to bypass the bundling edits in place for shoulder arthroscopy procedures unless the services are performed on separate shoulders.
Shoulder anatomy

Coding Debridement

CPT® code 29822 Arthroscopy, shoulder, surgical; debridement, limited includes debridement of soft or hard tissue. Debridement in a single area of the shoulder is considered limited debridement. CPT® code 29823 Arthroscopy, shoulder, surgical; debridement, extensive includes debridement of multiple soft structures, multiple hard structures, or a combination of both.
Limited and extensive debridement are included in other shoulder arthroscopy procedures, even if the debridement is performed in a different area of the same shoulder than the primary procedure. There are three exceptions to this rule. Per National Correct Coding Initiative (NCCI) edit guidelines, extensive debridement (CPT® 29823) performed in a different area of the same shoulder with any of the following arthroscopic shoulder procedures may be reported separately:
29824  Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
29827                  with rotator cuff repair
29828                  biceps tenodesis
Example: When an arthroscopic rotator cuff repair with debridement of the biceps tendon and debridement of the labrum is performed, you may report 29827 and 29823 because the bundling edit is removed from this code combination.
When an arthroscopic repair of a superior labrum anterior and posterior (SLAP) lesion is performed with debridement of the labrum and biceps tendon on the same shoulder, however, you may only report CPT® 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion. Per NCCI guidelines, the debridement (29823) is considered included in the primary procedure when performed on the same shoulder.

Coding Acromioplasty

The acromion is a bony process on the shoulder blade that extends toward the shoulder joint. It is a continuation of the scapular spine, and together with the collarbone, it forms the acromioclavicular joint. Subacromial impingement is a condition where the rotator cuff tendon is pinched between the humeral head and the acromion.
Arthroscopic surgery for shoulder impingement involves removing inflamed or tight structures (decompression) and shaving small amounts of bone (acromioplasty) to create a smooth, wide space. This procedure is reported with CPT® +29826 Arthroscopy, shoulder, surgical decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).
CPT® made +29826 an add-on code several years ago, which means it must be reported with a designated parent code and may not be reported as a stand-alone code. Be sure there is clear documentation that bony work was performed on the acromion to support this code.
If +29826 is the only procedure performed, CPT® advises you to report instead of 29822 or 29823. For example, if a subacromial decompression is performed alone, which usually involves debridement of soft tissues or bone removal, then report code 29822 instead of +29826. Likewise, if there is extensive work done in the removal of the soft tissue and bone, then report 29823 instead of +29826.

Coding Slap Tears

The labrum in the shoulder connects the glenoid with the head of the humerus and provides a cushion between the bones. A SLAP injury is a specific kind of labral tear in which the front (anterior) and back (posterior) areas of the labrum are torn where it attaches to the biceps tendon. There are four types of SLAP tears:

Type I: A partial tear or fraying of the edges of the superior labrum

Type II: The superior labrum is completely torn off the glenoid

Type III: A bucket-handle tear of the labrum, where the torn part of the labrum hangs into the joint

Type IV: The torn labrum extends all the way into the biceps tendon

Check the documentation to identify where on the labrum the surgery was performed. Many surgeons refer to “clock” positions. For example, “The labral tear was repaired with sutures placed at 10 o’clock and 1 o’clock.” This documentation indicates the surgeon worked on the upper half of the labrum, which supports 29807. Work on the bottom half of the labrum would be a capsulorrhaphy (29806 Arthroscopy, shoulder, surgical; capsulorrhaphy).
Per NCCI edits, you may not use modifier 59 Distinct procedural service to unbundle these procedures if they are performed on the same shoulder. If both upper and lower areas of the labrum on the same shoulder are repaired at the same session, append modifier 22 Increased procedural services to the code to acknowledge the additional work performed.

Coding Scope to Open Procedures

Some arthroscopic procedures require immediate conversion to an open surgical procedure. When this happens, you may only report the open surgical procedure. However, you may append modifier 22 to the open procedure code to support the additional work performed arthroscopically.
Example: The surgeon begins a rotator cuff repair arthroscopically but converts to an open approach to finish. Report only the appropriate “open” CPT® code (23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute or 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic). You may report 23410 or 23412 with modifier 22 appended to account for the arthroscopic work done prior to the open portion of the procedure. Do not report both the open and arthroscopic codes with modifier 59 because the work was performed in the same anatomic location during the session.
Coding for arthroscopic shoulder surgery is complex, and coding errors are common. Although the information in this article is not exhaustive, it’s important. Staying up to date on coding and documentation requirements ensures proper claims payment and quality data.

About the author:
Carol Ermis, CPC, COSC, AAPC Fellow, is the billing director at Orthopaedic Specialists of Austin, Texas, where she’s managed the revenue cycle for 13 years. She serves on the advisory board for The College of Health Care Professions and is a member of the Austin, Texas, local chapter.

3 Responses to “Update Your Understanding of Shoulder Arthroscopy Codes”

  1. Sarah says:

    CMS has updated their wording since this article was published. They no longer consider the shoulder a “single anatomic structure”.

  2. Renee Dustman says:

    Chapter 4 of the NCCI guidelines state:
    4. With three exceptions (which are described in Chapter IV, Section E (Arthroscopy), Subsection #7), an NCCI PTP edit code pair consisting of two codes describing two shoulder arthroscopy procedures shall not be bypassed with an NCCI PTP-associated modifier when the two procedures are performed on the ipsilateral shoulder. This type of edit may be bypassed with an NCCI PTP-associated modifier only if the two procedures are performed on contralateral shoulders.
    This essentially means that each shoulder is considered a single structure.
    — Carol Ermis

  3. Ashley Hillestad says:

    AAOS states you can bill 29826-59 with 23410 & 23412. I haven’t seen an updated changing this ruling and can’t find any other documentation stating this or debunking this. Can you provide guidance for this?
    Thank you,