Revenue Cycle Insider

Question: I’m having trouble assigning codes based on the following information from an op note:

We then began to evaluate the [shoulder] joint. The cartilage surfaces on the humeral head and glenoid were healthy in appearance. The patient has moderate fraying along the lateral margin of rotator cuff, which was debrided with a shaver. Otherwise, the rotator cuff appeared intact. The biceps had fraying in its insertion site. There was significant erythema along the anterior capsule which was debrided with a shaver and cautery. The labrum had degenerative changes circumferentially and was debrided back to a smooth surface with cautery as well. The biceps tendon was then tagged with a FiberWire suture and released from its superior margin. The tagging stitch was then incorporated with a 4.75 mm SwiveLock anchor to create our biceps tenodesis. The instruments were then removed and placed in the subacromial space. The lateral portal was established. Extensive amount of bursitis was cleared off of the undersurface of the acromion and superior aspect of the rotator cuff. The rotator cuff appeared intact in the superior margin as well. The anterolateral margin of acromion had several bone spurs which were debrided back to a smooth surface with a bur.

What codes do you recommend?

Missouri Subscriber

Answer: Use 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) as the primary procedure code to report the biceps tenodesis procedure.

Next, you’ll want to examine the op note for the description of the debridement. The CPT^® code book features two codes for arthroscopic debridement of the shoulder:

• 29822 (Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]))
• 29823 ( … debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]))

In the op note provided, the surgeon performed moderate debridement on the rotator cuff, but they also cleared a significant amount of bursitis from the rotator cuff. This means the surgeon should seek reimbursement for the extensive debridement on the shoulder.

Code 29823 carries another requirement for reimbursement, and that is the number of body structures that the surgeon debrided. The structures debrided in the op note include the rotator cuff, labrum, bone spurs, and shoulder bursa. You cannot count the biceps tendon because that procedure is coded with 29828.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC