Orthopedic Coding Alert

Bonus: Learn when your physician's requests will throw your coding out of joint.

To properly report shoulder procedures, you have to know what to report -- and when. Just as important, you have to remember what not to report to stay out of auditors' cross hairs. Try your hand at three of the most challenging operative notes that Beth P. Janeway, CPC, CCS-P, CCP, shared during a Coding Institute teleconference. A thorough knowledge of shoulder anatomy is crucial because you more readily know what your orthopedist is doing, says the Winston-Salem, N.C.-based consultant. And being acquainted with anatomy will give you a sound understanding of when you should claim open procedures, she adds.

Arthroscopy Plus Arthrotomy? Use 1 Code

Scenario 1: A 20-year-old male was playing football with friends and was tackled, dislocating his right shoulder. The provider reduced it in the emergency department (ED) and sent the patient to physical therapy, but the patient feels his shoulder is still unstable.

The orthopedist performs a physical exam, which demonstrates a positive anterior apprehension sign, and the patient has a normal neurological exam. X-rays of the shoulder are negative, but magnetic resonance imaging (MRI) reveals a large Bankart lesion.

Arthroscopic evaluation demonstrates a large Bankart lesion with a significant Hill-Sachs lesion. The orthopedic surgeon converts to an open procedure and performs an arthrotomy. He repairs the glenoid labrum, but the shoulder remains unstable, so he places a bony block anteriorly to further stabilize the shoulder. The surgeon then closes the wound and places the patient in a shoulder immobilizer.

Watch out: In cases like these, many physicians want coders to use 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy [separate procedure]) plus an arthrotomy code, Janeway warns. "That is not OK," she says. Instead, you should use the open code alone, even though the physician did an arthroscopic exam before opening.

Exception: "The only time you would use an arthroscopic code as well as an open code is when the scope is a completely separate part of the procedure," Janeway says. For example, you could code for both if the surgeon did something arthroscopically in one shoulder area and then opened up another part of the shoulder to do something else.

Coding solution: Consequently, you would correctly code scenario 1 as 23460-RT (Capsulorrhaphy, anterior, any type; with bone block; right side).

Time May Be Key for Code Choice

Scenario 2: A 48-year-old ED physician falls off his bicycle and fractures his clavicle. In his ED, he undergoes a figure-of-eight splint, which he removes after 10 days. Four weeks later, he presents to a local orthopedist, his friend, who advises him to immobilize the shoulder -- which he refuses. After eight weeks there is motion at the fracture site, and it is painful. The orthopedist suggests electrical stimulation, which the patient tries for eight weeks with no relief of symptoms. After three months, x-rays reveal hypertrophic nonunion of the clavicle, and the orthopedist recommends open reduction with internal fixation (ORIF).

Intraoperatively, the orthopedic surgeon secures the fracture with a plate and screws. He then shaves the hypertrophic bone and uses it for a bone graft. The patient returns to full activities three months postoperatively and is pain-free, but he now complains the plate is prominent.

Know your options: This patient's shoulder saga presents you with a few coding choices, given the time that elapsed between the injury and the surgery, Janeway says. You could consider 23485 (Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion [includes obtaining graft and/or necessary fixation]). After all, if you look through the note, the patient does have a nonunion, and it has been a few months since he injured himself. On the other hand, because only two months have passed since his injury, you might be tempted to use 23515 (Open treatment of clavicular fracture, includes external fixation, when performed), Janeway says.

But you should stick with 23485 with 733.82 (Nonunion of fracture) and 905.2 (Late effect of fracture of upper extremities) as your supporting diagnoses, says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, an independent coding consultant in North Dakota. Code 23485 more accurately reflects the additional work involved in secondary repairs, she says. "The key is the work involved, noting that an acute fracture involves less work than a nonunion, similar to other CPT hierarchies as secondary repairs, which may be performed anytime after the initial repair."

Acute or Chronic? There's a $60 Difference

Scenario 3: A 61-year-old male general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem.

The orthopedist's physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear.

The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs  subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.

First, the labral debridement and the rotator cuff: A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear. You should begin with 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), although you'll need to append a modifier when you add other codes. You should then address the open rotator cuff repair, using 23412  Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic).

How to decide between 23410 and 23412: If you choose 23410 (... acute) instead of 23412, you will gain about $60 more reimbursement for this part of the surgery, but "acute" is not appropriate in this case. "He's been having this pain for over six months," Janeway says. "Acute" describes pain that began more recently, certainly within the past six months.

Next, the subacromial decompression: Now you should look to the arthroscopy codes, Janeway says. The next codes on your claim should be 29824-51 (... distal claviculectomy including distal articular surface [Mumford procedure]; multiple procedures) and 29826-59 (... decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; distinct procedural service).

Why modifier 51 and 59? The Correct Coding Initiative (CCI) bundles 29826 into 23412, but you can override that edit in this case with modifier 59. CCI does not bundle 29824 with 23412, Janeway says, so you don't need modifier 59 to override that edit. You simply need modifier 51 to indicate multiple procedures. After all, "you don't want to use modifier 59 unless you have to," Janeway says. Keep in mind that some payers' software, such as with Medicare's, automatically applies modifier 51 for multiple procedure claims. Ask your payers whether you need to use this modifier.

Final coding: Your final codes should look like this:

• 23412 for the open rotator cuff repair
• 29826-59 for the arthroscopic acromioplasty
• 29824-51 for the arthroscopic distal clavicle excision
• 29823-59 for the arthroscopic extensive debridement.

Note: To order a CD or transcript of Janeway's presentation, "Surefire Strategies for Coding Shoulder Procedure," go to www.audioeducator.com.