Orthopedic Coding Alert

Process and records influence your claims

When your orthopedic surgeon treats a chronically unstable shoulder, you'll need to follow the route taken for capsular repair and note the procedures done to correct the instability for this common condition. Read on for advice on how to more accurately report your shoulder instability claims.

Review Shoulder Joint Anatomy

A refresher in shoulder (glenohumeral) joint anatomy will ease your coding for dislocation corrective procedures. The anatomy and range of motion in the glenohumeral joint is maintained by the geometric conformity of the articular surfaces, the deepening of the glenoid fossa due to the labrum which forms a rim at its margins, and the action of the muscular forces which compress the humeral head into the glenoid fossa. A compromise in any of these forces may result in an unstable shoulder that dislocates once or many times. The anterior inferior part of the labrum is most likely to avulse (termed a "Bankart lesion"); hence, most dislocations occur in the anterior part of the capsule, though posterior and inferior are also possible.

Coding tip: Your surgeon's notes may include details on what part of the capsule was affected, which will influence your code choice.

Report the Emergency Services

Patients with shoulder dislocations typically present to the ER with pain after a fall on an outstretched hand, requiring the orthopedic surgeon attending to the patient in the emergency to manipulate the shoulder joint back into position to reduce the dislocation. "Shoulder dislocations can be treated in the ER usually by manipulative reduction under some type of anesthesia," says Denise Paige, CPC, COSC, orthopedic coder, Bright Health Physicians, Whittier, CA. If the procedure was done without anesthesia, you report 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia).

If you read that the orthopedic surgeon attending to the patient in the ER sedated the patient to keep the patient calm yet conscious while performing the reduction, you also report for the conscious sedation. Example, if the surgeon who is doing the closed reduction also performs the sedation for 30 minutes or less in a patient who is more than 5 years in age, you report 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports ...; age 5 years or older, first 30 minutes intra-service time) and 23650. There are specific documentation criteria that apply to reporting a conscious sedation and an appropriate code should be chosen," advises 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. However, if the same manipulation is done under anesthesia, you report 23655 (Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia).

Catch the Direction of Instability and Repair

Open repair is done in a shoulder that dislocates often and fails to respond to a closed reduction. "If the shoulder shows signs of instability after a dislocation, by repeated dislocations, then surgical repair would be necessary, such as a capsulorraphy," says Paige. "Most instability stabilization procedures are now done arthroscopically. The indications for performing an open procedure now are failures of arthroscopic stabilization (especially multiple failures), in cases of bone loss on the glenoid rim (a bony Bankart lesion), or humeral head (an engaging Hill-Sachs lesion), or in some cases of what is termed "multidirectional instability (MDI)," explains Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

In a patient in whom the antero-inferior labrum is torn (the Bankart lesion), the surgeon will likely repair the labrum. The labrum is a rim of soft tissue that surrounds the glenoid cavity. If you read in the note that the surgeon made a long incision to cut through the deltoid muscle keeping lateral to the coracoid process, retracted the cephalic vein laterally and cauterized the twigs of the thoraco-acromial artery in the clavipectoral fascia to expose the joint capsule, this is your cue for an open repair. "A delto-pectoral approach is commonly used for repairing the Bankart lesion," says Mallon. You may further read that the labrum was identified and anchoring sutures were placed to repair the labrum and attach it to the joint capsule. You then report code 23455 (Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)). "A labral repair is done to repair a tear in the labrum, the tissue structure that adds stability to the shoulder joint by giving support to the glenoid," says Paige.

Your surgeon may retrieve a bone graft from the iliac bone and insert it in the anterior glenoid area to prevent a recurrent anterior dislocation. "A bone block is one type of repair for a recurrent shoulder instability. That part of the procedure would need to be in the title of the report and repeated in the body of the report, indicating that a bone block was added to the glenoid to repair significant damage to that area of the joint," advises Paige. You report 23460 (Capsulorrhaphy, anterior, any type; with bone block) for such a procedure. Another method of repair is where the surgeon transfers the tip of the coracoid to the glenohumeral capsule and to the tip of the anterior glenoid periosteum. The biceps and coracobrachialis attached to the tip of the coracoid provide dynamic restraint to inferior and anterior instability, especially in abduction and external rotation and hence help to stabilize the shoulder.

Example: You may read that the surgeon transferred only the tip of the coracoid along with the attached muscles and ligaments, leaving behind the base. If your surgeon notes that he "transferred the coracoid process to the anterior glenoid neck, leaving behind the base and the coracoclavicular ligaments and a part of the coracoacromial ligament attached to the transferred coracoid process and the muscle was imbricated into the anteroinferior glenohumeral capsule for further stability," you would report code 23462 (Capsulorrhaphy, anterior, any type; with coracoid process transfer) to specify the coracoid transfer. "The Latarajet or Bristow-Latarajet procedure is reported as 23462," says Mallon. The Putti-Platt or Magnuson-Stack procedures are now archaic," he adds. Thus, code 23450 (Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation) is rarely used now.

Your surgeon will adopt a posterior approach to repair a chronic posterior instability due to either posterior labral fraying and tears or a patulous capsule. When you read in the operative note that the surgeon "placed an incision over the posterolateral border of the acromion extending to the axilla, exposed the capsule by splitting the deltoid, dissected through the interval between the infraspinatus and teres minor," you can justify reporting a posterior repair. When you further read that the surgeon retracted the humeral head to expose the posterior glenoid rim and inserted sutures that were tied to repair the capsule, you report code 23465 (Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block).

Example: Let's review another operative scenario: "The stability of the joint was assessed under general anaesthesia and the shoulder was abducted in a prone patient. An incision was made over the spine of the  scapula, the deltoid was detached, and the infraspinatus and teres minor were retracted apart. The joint capsule was opened to inspect the joint cavity. Bed for bone block was then created in the posterocaudal part of the scapular neck. The posterior part of the iliac crest was approached by incising over the bony prominence and a tricortical bone graft, about 3 cm long was obtained. The bone block was fixed with 2 AO-screws at the posterocaudal glenoid rim such that the block did not protrude laterally to the posterior labrum. After the deltoid was inserted back, the incision was closed. A velpeau plaster cast was applied for eight weeks." This is typical description of a posteriorbone block procedure for which you report code 23465.

When a patient has multidirectional instability (MDI), the open procedure that will often be performed is called an "inferior capsular shift" and you should look for this term to indicate that the surgeon is treating MDI. You report code 23466 (Capsulorrhaphy, glenohumeral joint, any type multidirectional instability) for repair of the capsule deficiency that was causing instability in more directions than one. "MDI is a common encounter in clinical practice and a capsular shift procedure is fairly common," says Mallon.

Report the Splints or Straps

The codes for dislocation are inclusive of the initial splints or strapping. You report the splint or strapping only when any code for the dislocation per se is not reported by the attending surgeon. "If the shoulder is reduced, any splint or strapping would be considered part of the treatment for the initial reduction and not separately billable," confirms Paige.

Example: If the X-Ray reveals a slight dislocation, the surgeon may strap the arm to immobilize it. You report29240 (Strapping; shoulder (eg, velpeau)) for the strapping that was done without any reduction maneuvers. Code 23465 is inclusive of the initial velpeau plaster cast that is provided at the conclusion of the procedure. You do not report 29240 in addition to 23465. "The CPT® reporting guidelines for the casting and strapping codes clearly state that these codes are reported when casting or strapping is a replacement procedure performed during or after the followup period. Codes in this series, say for example 29240, are not reported when performed in conjunction with any type of restorative procedure like 23465," says Stout.