Orthopedic Coding Alert

Question: Encounter notes indicate that the provider treated a patient with calcareous deposits in his left shoulder. The provider cuts into the deltoid muscle and through the fascia, and then creates a small opening in the subdeltoid bursa and accesses the bursa. After clearing out the calcaneal deposits, the provider cleans the surgical area and closes up the patient. How should I code this encounter?

Iowa Subscriber

Answer: As your provider performed an incision to access the bursa, this is an open removal. On the claim, you should report:

• 23000 (Removal of subdeltoid calcareous deposits, open) for the calcareous deposit removal.
• Modifier LT (Left side) appended to 23000 to indicate laterality, if the payer requires it.
• M75.32 (Calcific tendinitis of left shoulder) appended to 23000 to indicate the patient’s condition.

Note: If the provider had removed the calcareous deposits arthroscopically, you’d code 29999 (Unlisted procedure, arthroscopy) rather than 23000.