Orthopedic Coding Alert

Curettage and tendon repair are inclusive to 23000.

When your surgeon removes calcific deposits in the shoulder, you'll stand a better chance of capturing full reimbursement if you're well versed in the procedure's complexities, which typically include cutting the muscle, incising the bursa, and curettage of the cavity to remove the damaged tissue. "It is one of the most painful conditions in the shoulder that can come on acutely without an injury," offers Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Heed the advice below to hit the right code every time you report this procedure.

Let This Scenario Guide Your Open Procedure Coding

Though rare, you may encounter an open procedure to remove subacromial calcific deposits, as described in the op note that follows:

"The patient was placed with back on the table and folded sheets were used as supports under the shoulder blade and hip on the left side to raise the left shoulder. The patient was then drawn as close possible to the edge of the table such that when needed the elbow can be pushed backwards below the plane of the table to help explore the upper part of the bursa, if needed. An incision was then made directly anterior to the head of the humerus. The upper end of the incision was near the acromio-clavicular joint and at the lower end it extended to about the level of the top of the bicipital groove which could be felt in the patient. The deltoid was then excised and fibres were cut upward and downward to equal the length of the skin incision.

The upper surface of the roof of the bursa was then exposed by using small broad retractors. The white shiny floor of the bursa was seen and all cut vessels were secured to prevent bleeding. The roof of the bursa was cut through and the incision was enlarged. The attachments of the tendons were inspected by rotating the arm through the full arc while the wound is held open. The calcareous deposits in the supraspinatus tendon were palpated and were felt to have the consistency of an ointment. Upon incision, the white material escaped under tension and the rest of the deposits were cleared by gentle curettage. The cavity was then washed to remove the debris. The roof of the bursa and the overlying muscle and skin were closed."

Hit the Right Code

You report CPT® code 23000 (Removal of subdeltoid calcareous deposits, open) for the procedure described. Note that the curettage of the cavity to remove the deposits and the repair of the incised tendons and muscles is all inclusive in this single code.

The American Academy of Orthopedic Surgeons (AAOS) specifies that code 23000 for open removal of calcareous deposits below the deltoid should not be reported in addition to 23412 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic). "AAOS and CCI bundle 23000 to the approach for the rotator cuff repair service," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. "CPT® code 23000 would only be reported if performed on the contralateral shoulder per bundling edits."

Tendon fix: When your surgeon repairs a tendon, you only report the tendon repair service as this is inclusive of removal of deposits, debridement, or curettage. "If removing deposits that require tendon repair, the tendon repair service is the more comprehensive, reportable service," says Stumpf. "Removal of the calcium deposits would be inherent in the tendon repair. Debridement or curettage of the repair site is included in tendon repair services."

Document the Complex Cases and Use Modifier

You will append modifier 22 (Increased procedural services...) if there is extensive work involved in a complex case. "If the debridement of the calcific deposits leads to significant increased complexity, the 22 modifier may be utilized," says Stumpf. Make sure you adequately document the complexity of the procedure and the medical necessity for the same. "A separate and distinct paragraph is recommended labeled 'case complexity,' '22 modifier description,' or some language that identifies the paragraph as supporting documentation for 22 modifier use. This will aid in rapid claims processing for 22 modifier review," says Stumpf.

Tip: If your surgeon does arthroscopic removal of bursal deposits, you turn to the debridement code and bill for 29823 (Arthroscopy, shoulder, surgical; debridement, extensive). "This would be included in the debridement services. Per AAOS, arthroscopic debridement includes soft and hard tissue debridement," says Stumpf. You report 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e. arch] release, when performed [List separately in addition to code for primary procedure]) for acromioplasty. "It is almost done with acromioplasty," says Mallon.

Also confirm if your surgeon is doing a tendon repair when removing the calcific deposits. You report 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) for tendon repair done during the arthroscopy. "The calcific deposits are debrided out of the tendon and if the defect is large enough, the tendon is repaired, in which case I report 29827-22," says Stout.