Orthopedic Coding Alert

Question: After a level-three evaluation and management (E/M) office service for an established Medicare patient, the provider performs a diagnostic arthroscopy of the left shoulder. She then performed a limited arthroscopic debridement of the same shoulder. How should I report this encounter? Can I report both arthroscopies?

Florida Subscriber

Answer: In this case, you’ll need to observe the multiple endoscopy rule for this encounter (more on that later). On your claim, report the following:

• 29822 (Arthroscopy, shoulder, surgical; debridement, limited) for the surgical arthroscopy
• Modifier LT (Left side) appended to 29822 to indicate laterality, if the payer requires it
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99203 to indicate that the E/M preceded the procedure.

Why 1 arthroscopy code? You’ll only choose a single arthroscopy code because the multiple endoscopy rule is in effect. Simply put, this rule is Medicare’s way of avoiding double payment if the provider uses the same endoscopic service for both procedures.

The multiple endoscopy rule dictates that you cannot code scopes from the same arthroscopy “family” with multiple codes if one of those codes represents the “base” code for that family. In these cases, it’s best that you choose the more extensive code for your claim; in your case, the 29822 code overrides 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)) — which is the “base” code for this code set.

Reason: All surgical shoulder arthroscopies include a diagnostic service, so 29822 is the more extensive code.  

Exception 1: The multiple scope rule does not apply when the provider performs multiple endoscopies that are not members of the same code family. For example, if the provider performs a diagnostic knee arthroscopy and a shoulder arthroscopy for surgical repair of a SLAP lesion (Superior Labral tear from Anterior to Posterior), you’d report 29807 (… repair of SLAP lesion) for the SLAP repair and 29870 (Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)) for the knee scope. Since these endoscopies occur in different anatomical areas, there’s no need to worry about the multiple endoscopy rule.

Exception 2: When the orthopedist performs multiple endoscopies from the same code set without a “base” code, you’ll report both endoscopies, and the payer will apply the multiple procedures pay model to the claim.

Exception 3: The multiple scope rule is officially on the books for Medicare payers — and payers that follow Medicare’s lead. Some private payers, however, might not follow the multiple scope rule. If you’re not sure about the rule’s application to a specific payer, check your contract before coding.