Orthopedic Coding Alert

Do not miss the repair when your surgeon does one.

You’ll stand a better chance of acing your wrist arthroscopy reporting if you’ve clear on your surgeon’s visualization, lavage, and synovectomy services. See the examples below on identifying these and other needed specifics in the operative note so that you’ll arrive at the right code.

Confirm the Diagnostic Intent

You may read that all your surgeon did was to take a look at the structures in the wrist joint. Your surgeon may be attempting to check the pathology in the wrist and may even attempt to snip a piece of tissue for a microscopic examination.

Example: Check out this operative note example that confirms the visualization of the structures in the wrist joint for diagnostic purposes.

“Under general anesthesia, the hand was suspended with 10–15 lbs. of counter traction. The upper arm tourniquet was inflated to 250 mm Hg. to exsanguinate the arm. We made a portal between the 1st and 2nd extensor compartments. Using a 22-gauge needle angled 10° volarly, we identified the radiocarpal joint. Using blunt forceps, the soft tissues were spread and the dorsal capsule was pierced. A portal was made in the concavity between the EPL and the EDC, just distal to Lister’s tubercle, in line with the 2nd webspace. Slightly proximal and about a cm ulnar to this portal, we made another portal. Two more portals were made, one on the radial side of the ECU tendon, just distal to the ulnar head and another one on the ulnar side of this tendon. The radiocarpal joint space was identified and 5 cc of saline was injected and the joint was inflated. The cartilaginous surfaces of all articulations were examined. The scapho-lunate, radioscaphocapitate, long radiolunate, radioscapholunate, ulnolunate, and ulnotriquetral ligaments, and the triangular fibrocartilage were visualized…..we switched scope to 4/5 portal to view the ulno-carpal ligaments and luno-triquetral ligaments.”

What to report: In this case, you confirm that your surgeon is only viewing the structures in the wrist to identify the pathology and you report code 29840 (Arthroscopy, wrist, diagnostic, with or without synovial biopsy [separate procedure]). If your surgeon does a synovial biopsy during the diagnostic arthroscopic visualization, you would also use 29840. “Biopsies are included in the global service package, and in the descriptor for CPT^® code 29840,” says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. 

Lavage Leads You to a Specific Code

Your surgeon may do a lavage and drain out infected tissue to clean up the infection in the wrist.

Example: The operative note may read, “Examination showed marked synovitis around the ulnocarpal joint though the cartilage was intact. Lavage was performed with copious volume of isotonic saline. The adequacy of drainage was assessed and confirmed.”

What to code: In this case you confirm that your surgeon does the lavage and you report code 29843 (Arthroscopy, wrist, surgical; for infection, lavage and drainage).

Check the Extent of Synovectomy

Your surgeon may do an arthroscopic synovectomy in a patient with rheumatoid arthritis and recalcitrant synovitis. To code these services accurately, you need to confirm the extent of synovectomy.

Example: You may read that your surgeon removed only the inflamed part of the synovium. Check out the sample procedure note below: 

“A 2.7-mm diameter, 30º arthroscope was introduced through a 3/4 portal. The 6U portal served as a working portal in the radiocarpal joint. Other working arthroscope portals included the mid-carpal radial, mid-carpal ulnar, and scaphotrapeziotrapezoid portals. The inflamed part of the synovium was removed using a motorised shaver, without thermal coagulation.”

What to code: Because you’ve confirmed from the op note that your surgeon did a partial synovectomy, you can report code 29844 (Arthroscopy, wrist, surgical; synovectomy, partial).

Your surgeon may perform an extensive synovectomy; see the following sample note for a complete synovectomy:

“With the patient in general anesthesia and forearm suspended in traction, a tourniquet was applied to the upper arm……..there was hypertrophic synovium in the ulnocarpal joint and the triangular fibrocartilage appeared disrupted…….We used the 3-4 and 4-5 portals for access to the radiocarpal joint and radial and ulnar portals were used for the mid-carpal joint. For complete access to all areas of the radiocarpal and midcarpal joints to enable adequate excision of the synovium, additional portals were used….. synovectomy was done using a motorized shaver system and 2.4 mm diameter 30° arthroscope…All segments of the visibly inflamed synovium were resected down to the joint capsule.”

What to code: This specifies that all of the synovium was removed, so you would turn to code 29845 (Arthroscopy, wrist, surgical; synovectomy, complete) for complete arthroscopic synovectomy. “Documentation is the key for reporting of these services,” says Stumpf. “CPT^® code 29845 would be utilized when your provider clearly states that the entire synovium was removed for prolific synovial pathology throughout the wrist.  Removal of the synovium from one area of the wrist, intercarpal or radiocarpal, would likely support the use of 29844 as a ‘complete’ synovectomy has not been performed.”

Best practice: “Educate your surgeons on the importance of using the language of CPT^® (partial or complete) in their operative statement when they perform an arthroscopic wrist synovectomy.  Doing so communicates to the payer the extent of the procedure as determined by the surgeon,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Do Not Miss the Repairs Done

If you read that your surgeon identified the tear in the triangular fibrocartilage and repaired (or excised) the same with sutures, you report code 29846 (Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement).

Your surgeon may also attempt fixation of wrist fractures through the arthroscope.

Example: For the repair of an acute scaphoid fracture, your surgeon may document the following in the operative note:

“Following fluoroscopic guide wire insertion, the arm was suspended in traction and the reduction was visualized. Other injuries in the carpal area were identified. Iliac bone graft was percutaneously injected by advancing the arthroscopic canula down the guide wire and into the drill hole in the proximal scaphoid. The wrist was then taken out of traction and a screw was placed.”

And take a look at another example of an operative note where you confirm arthroscopic fixation of a wrist fracture in a patient who reported with wrist trauma.

“Standard 3.4 and 6.0 portals were used to accomplish arthroscopic exposure of the wrist and the fracture hematoma was taken off. The displaced articular surface was then visualized. Using pins, the surfaces were reduced and stability for the minimal range of motion was confirmed radiographically.” In this case, you report 29847 (Arthroscopy, wrist, surgical; internal fixation for fracture or instability).

Heed Advice for Same Session Repairs

Don’t be taken by surprise if you read that your surgeon did the fracture reduction and the triangular fibrocartilage (TFCC) repair in the same session. You may report 29846 and 29847 together in this case, provided you confirm the same with your payer. “Some private payers may reimburse both the services,” says Stumpf.  “AAOS GSDG does not list the repair of the triangular fibrocartilage as specifically inclusive or exclusive in code 29847.  The descriptor for code 29847 clearly states ‘fixation for fracture OR instability,’ not ‘AND instability.’  This would lend support to separate reporting if distinct and separate repairs were performed for fracture and for the triangular fibrocartilage.  Due to the same arthroscopic approach, the 51 (Multiple procedures) modifier would be the most appropriate modifier.”

Also: CCI bundles 29846 and 29847. “AMA considers all compartments of the wrist as one and debridement is inclusive in fracture repair,” says Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. “Code 29847 has the higher RVU (16.17for 29847 vs 15.46 for 29846) and should be sequenced first. The American Society for Surgery of the Hand (ASSH) allows for separate reporting. If your payers do not follow CCI, fracture reduction and TFCC repair could be reported with a 59 modifier on 29846, using ASSH as your supporting official resource.”