Analyze Arthroscopic Shoulder Surgical Procedure Coding Rules
Don’t report 2 codes when only 1 is needed. Orthopedic procedures on the shoulder can be tricky to code for even the most experienced coders, but with an understanding of the anatomy, knowing what to look for in the documentation, and a firm grasp on coding guidelines and policies, you’ll have the confidence to code most procedures. Read on to learn how to elevate your shoulder procedure coding skills. Get Familiar With Shoulder Anatomy Knowing the different bones, ligaments, tendons, and muscles of the shoulder joint will help you recognize the terms and better understand the op note while you’re coding procedures. A shoulder operative report can contain several common terms, including: One structure in particular that is made up of multiple tendons is the rotator cuff. “The rotator cuff contains four tendons, which are the supraspinatus, the infraspinatus, the subscapularis, and the teres minor,” explained Mary Bort, CPC, CPMA, CANPC, CASCC, COSC, senior coding quality auditor at the Haugen Consulting Group during her “Breaking Down Shoulders: An Elevated Approach to Coding Shoulder Operative Notes” session at AAPC’s HEALTHCON 2025. Dive Into the Documentation A strong knowledge of anatomy is very helpful when you’re faced with unfamiliar procedures in op notes. For example, SLAP tears are injuries that you may see in surgical reports. SLAP stands for superior labrum, anterior to posterior, and they’re referred to as labrum tears. “A clear understanding of the anatomy and of the tears are essential in coding the SLAP tears correctly. The SLAP injury involves the top part of the labrum where the biceps tendon attaches to the labrum. Then the slap occurs in both the front, which is the anterior, and the back, which is the posterior, of the attachment point,” Bort explained. SLAP tears are categorized in four types: However, you cannot assume that one type is more severe than another based on the number category. You need to thoroughly review the medical documentation to identify the SLAP tear type. “It’s really your physician’s responsibility to make sure that they are documenting what that level, what that type is, and that’s going to drive your coding decision as well as in that documentation,” Bort stated. Know the NCCI Rules for Separate Procedure Billing Orthopedic surgeons may need to perform minor procedures during the course of a complex operation. Can you bill the minor procedures separately? No, not if the minor procedure is needed during the other procedure. Scenario: A surgeon performs shoulder manipulation with the patient under anesthesia to assess the patient’s range of motion prior to performing arthroscopic shoulder surgery. In this scenario, you cannot separately report 23700 (Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)) and 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair). “If a shoulder manipulation is done during the same encounter as any other shoulder procedure, it’s not going to be separately billable. That’s the same within the entire musculoskeletal portion of your CPT® code book,” Bort said. According to Chapter 4 of the 2025 Medicare National Correct Coding Initiative [NCCI] Policy Manual, “When it is necessary to perform skeletal/joint manipulation under anesthesia to assess range of motion, reduce a fracture or for any other purpose during another procedure in an anatomically related area, the corresponding manipulation code is not separately reportable.” Scenario: The provider performs synovectomy to clean up the shoulder joint. After the synovectomy, the surgeon was able to visualize the rotator cuff and proceeded with the arthroscopic rotator cuff repair. In this scenario, the provider was unable to see the rotator cuff and performed a synovectomy to better see and approach the rotator cuff. This is another scenario where the first procedure cannot be billed separately from 29827. According to Chapter 4 of the NCCI policy manual, “A synovectomy to ‘clean up’ a joint on which another more extensive procedure is performed is not separately reportable.” Learn How to Report Procedure Changes You might have op notes in your workflow that describe the surgeon transitioning from one procedure or approach to another. In those cases, you’ll need to know the rules about reporting the procedures. Scenario: A surgeon starts an arthroscopic rotator cuff surgery but decides to switch to an open procedure after recognizing severe damage to the structure. The surgeon makes an incision and completes the rotator cuff repair as an open procedure. Even though the physician began the operative session with an arthroscopic approach, you will report the open procedure code for the surgery. The Medicare NCCI coding policy manual instructs that “[if] an arthroscopic procedure is converted to an open procedure, only the open procedure may be reported.” At the same time, if a diagnostic procedure leads to surgery during the same encounter, then you’ll report just the surgery code. Scenario: The surgeon begins diagnostic arthroscopy on a patient’s shoulder following complaints of front of shoulder pain, upper arm pain, and a snapping sound in the shoulder. After examining the patient’s shoulder, the physician performs arthroscopic biceps tenodesis surgery. The Medicare NCCI coding policy manual once again instructs you to not report both the diagnostic and surgical arthroscopy codes together. “If a diagnostic arthroscopy leads to a surgical arthroscopy at the same patient encounter, only the surgical arthroscopy may be reported,” the agency writes. Therefore, it is incorrect to report 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)) with 29828 (… biceps tenodesis). Instead, your claim should only include 29828 for the biceps tenodesis procedure. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
