Orthopedic Coding Alert

Note surgical technique to avoid coding confusion.

Patients presenting to the orthopedist for shoulder problems will often require a shoulder arthroscopy. Once you identify the procedure as an arthroscopy, however, your coding choices expand rather than contract.

The lowdown: There are more than a dozen shoulder arthroscopy codes; one for diagnostic services, and the others for various surgical techniques to treat the patient.

Choose the correct arthroscopy code every time with this expert advice.

Mark 29805 for Dx Arthroscopy

The first step in deciding the correct shoulder arthroscopy code is identifying whether the procedure is diagnostic or surgical. For diagnostic arthroscopies, you'll report 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)).

The difference: "If the surgeon is performing a diagnostic arthroscopy, he would just be moving the scope through the shoulder and noting any abnormalities or injuries," explains Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. If the arthroscopy is surgical, the provider's notes would describe treatment for the injuries - not just notes on the injury.

Example: A new patient reports to the orthopedist with complaints of right shoulder pain. After a detailed examination and history, the orthopedist decides to perform an arthroscopy without a synovial biopsy. Her operative notes indicate that the patient suffered no structural or tissue damage, so the orthopedist prescribes rest and ibuprofen for the patient, with instructions to follow up if the pain persists.

In this scenario, the orthopedist performed an evaluation and management (E/M) service before deciding on the arthroscopy - but she did not make any fixes. Therefore, you'd report the following codes:

• 29805 for the arthroscopy
• Modifier RT (Right side) appended to 29805 to indicate laterality, if the payer requires the modifier
• 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 evaluation and management (E/M) service
• Modifier 57 (Decision for surgery) appended to 99203 to show that the E/M and arthroscopy were separate services.

Drop Dx Arthroscopy Code when Surgery Occurs

As Anderanin noted earlier, surgical arthroscopy reports include descriptions of the patient's condition; if the provider performs a surgical arthroscopy, the notes would include details on treatments she performed during the arthroscopy - not just a description of the injury.

Most of the claims Anderanin sees include a diagnostic and surgical arthroscopy; if the provider performs both procedures on the same shoulder during the same treatment session, then 29805 is bundled into the other surgical procedure, Anderanin notes. So, if the provider performs a diagnostic arthroscopy that leads to a surgical procedure, you'll only report the surgical arthroscopy code.

Example: An established patient reports to the orthopedist for a scheduled left shoulder arthroscopy. The orthopedist notes a loose, and potentially foreign, body in the area. She removes the suspect body during the course of the arthroscopy.

Since the orthopedist found and repaired a problem in the shoulder during the procedure, this is a surgical arthroscopy - meaning the diagnostic arthroscopy (29805) is part of the surgical package and not separately reportable. On the claim, report 29819 (... with removal of loose body or foreign body) for the surgery.

Scour Notes for Surgical Arthroscopy Type

Once you've decided that the arthroscopy is surgical, you'll need to start narrowing down your code choice further. According to Anderanin, here are some of the more common injuries suffered by patients who need surgical arthroscopy:

• Shoulder pain,
• arthritis,
• adhesive capsulitis,
• recurrent dislocation/instability,
• rotator cuff rupture or tear,
• labrum tear or rupture, SLAP lesion
• biceps tendon rupture, tear, or tendinitis
• shoulder impingement,
• synovitis,
• tenosynovitis, and
• osteoarthritis.

Note: This is not a complete, or an approved, list of diagnoses for surgical shoulder arthroscopies; these are injuries a patient might suffer before receiving a surgical arthroscopy. If you have any doubt as to a payer's policy concerning surgical arthroscopies and their approved diagnoses, contact your payer before filing the claim.

You'll have to get a good handle on the encounter specifics before deciding on a code, because surgical shoulder arthroscopy is spread over more than 10 different codes, including:

• 29806 - Arthroscopy, shoulder, surgical; capsulorrhaphy
• 29807 - ... repair of SLAP lesion
• 29821 - ... synovectomy, complete
• 29825 - ... with lysis and resection of adhesions, with or without manipulation
• +29826 - ... decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)
• 29827 - ... with rotator cuff repair.

Check CPT^® when Surgery 'Opens Up'

You'll also have different options if a surgical shoulder arthroscopy turns from an arthroscopic to an open procedure. If you are coding for an open surgical shoulder procedure, see the notes below the arthroscopy code in the CPT^® manual for more information. For example, under the descriptor for 29819, it reads "(For open procedure, see 23040-23044, 23107)."