Outpatient Facility Coding Alert

Published on Tue Jun 18, 2013 PDF

Tip: Payer guidelines show when you can report multiple repairs.

Coding for wrist arthroscopy is a snap once you understand the surgeon’s level of visualization and the extent of lavage and synovectomy. Our experts share examples from each area to illustrate what to look for in the operative note so you’ll always narrow your choices to the correct code.

Verify the Surgeon’s Intent

Sometimes the surgeon only takes a look at the wrist joint’s structures to check pathology or possibly snip a small piece of tissue for microscopic examination. The operative report might include notes about making portals between compartments for access, identifying specific structures (joints, ligaments, or tendons), or injecting saline for better visualization.

This type of procedure qualifies as a diagnostic arthroscopy. You have one code to report: 29840 (Arthroscopy, wrist, diagnostic, with or without synovial biopsy [separate procedure]).

Take note: If the surgeon completes a synovial biopsy during the diagnostic arthroscopic visualization, you would also report 29840.

“Biopsies are included in the global service package, and in the descriptor for CPT^® code 29840,” explains Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. 

Report a Different Code for Lavage

More extensive procedures might include the surgeon performing lavage and draining out infected tissue to clean up any infection in the wrist.

Example: The operative note may read, “Examination showed marked synovitis around the ulnocarpal joint though the cartilage was intact. Lavage was performed with copious volume of isotonic saline. The adequacy of drainage was assessed and confirmed.”

Performing lavage shifts the procedure from diagnostic to surgical. You should report 29843 (Arthroscopy, wrist, surgical; for infection, lavage and drainage).

Check the Extent of Synovectomy

If the patient has inflamed tissue in the joint, the surgeon might complete an arthroscopic synovectomy. To code these services accurately, first confirm the extent of synovectomy.

Example 1: Notes might indicate that the surgeon removed only the inflamed part of the synovium. This is known as a partial synovectomy, which you report with 29844 (Arthroscopy, wrist, surgical; synovectomy, partial).

Example 2: In other cases, the surgeon may perform an extensive synovectomy by removing/resecting all segments of the visibly inflamed synovium. When all of the synovium is removed, turn to 29845 (Arthroscopy, wrist, surgical; synovectomy, complete).

“Documentation is the key for reporting of these services,” says Stumpf. “CPT^® code 29845 would be utilized when your provider clearly states that the entire synovium was removed for prolific synovial pathology throughout the wrist. Removal of the synovium from one area of the wrist, intercarpal or radiocarpal, would likely support the use of 29844 as a ‘complete’ synovectomy has not been performed.”

Best practice: “Educate your surgeons on the importance of using the language of CPT^® (partial or complete) in their operative statement when they perform an arthroscopic wrist synovectomy. Doing so communicates to the payer the extent of the procedure as determined by the surgeon,” advises Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, N.J., and orthopedic coding division director for The Coding Network, LLC, in Beverly Hills, Ca.

Watch for Additional Repairs

Other repairs might be needed during the procedure, which can lead to additional codes on your claim. Consider these two common scenarios:

• The surgeon identifies a tear in the triangular fibrocartilage and repairs (or excised) the tear with sutures. You’ll report 29846 (Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement).
• The surgeon attempts fixation of wrist fractures or instability through the arthroscope. Submit 29847 (Arthroscopy, wrist, surgical; internal fixation for fracture or instability).

Know Payer Guidelines for Multiple Repairs

In extensive procedures, the surgeon might complete fracture reduction and triangular fibrocartilage (TFCC) repair during the same session. You can report 29846 and 29847 together in this case, provided you confirm payer approval.

“Some private payers may reimburse both the services,” says Stumpf.  “AAOS GSDG does not list the repair of the triangular fibrocartilage as specifically inclusive or exclusive in code 29847.  The descriptor for code 29847 clearly states ‘fixation for fracture OR instability,’ not ‘AND instability.’ This would lend support to separate reporting if distinct and separate repairs were performed for fracture and for the triangular fibrocartilage. Due to the same arthroscopic approach, the 51 (Multiple procedures) modifier would be the most appropriate modifier [in the professional setting].”

Final note: CCI edits bundle 29846 and 29847. “AMA considers all compartments of the wrist as one and debridement is inclusive in fracture repair,” says Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist for Twin Cities Orthopedics, P.A. “Code 29847 has the higher RVU and should be sequenced first. The American Society for Surgery of the Hand (ASSH) allows for separate reporting. If your payers do not follow CCI, fracture reduction and TFCC repair could be reported with a 59 modifier on 29846, using ASSH as your supporting official resource.”