Arthroscopic Elbow Codes - 29836 or 29838 or BOTH?


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My provider performed a four portal arthroscopic elbow procedure--right elbow extensive arthroscopic debridement and excision of posterolateral synovial plica . This is the clinical description of the procedure (from Medicare GCPI): "The physician performs elbow arthroscopy with the patient in a supine position. General anesthesia is preferred. The physician makes 1 cm portal incisions to insert the arthroscope into the elbow joint space. The five most commonly used portals are the lateral, anterolateral, anteromedial, posterolateral, and straight positions. The physician places the arthroscope into the elbow joint and examines the humeral-ulnar and radial-ulnar joints. The elbow is flexed and extended, and pronated and supinated to allow visualization and examination of all joint spaces and surfaces. If there is evidence of synovial proliferation or inflammation indicating disease, the physician uses an instrument to obtain a small piece of synovium for biopsy. In 29830, the physician performs a diagnostic arthroscopy. In 29834,
the physician examines all parts of the elbow joint with the arthroscope. Any loose bodies (e.g., small pieces of cartilage from chondral injuries) or foreign bodies (e.g., bullet or nail) are removed by identifying them through the arthroscope and using another portal incision to remove the object. In 29835, the physician may also perform a partial synovectomy, where in 29836 the physician may perform a complete synovectomy. In 29837, the physician performs a limited debridement. In 29838, the physician uses the arthroscope to examine all parts of the elbow joint. Debridement is performed on proliferative cartilage, a degenerative joint, or roughened or frayed articular
cartilage. The physician uses instruments through the arthroscope to cut and remove inflamed and proliferated synovium and to clean and smooth the articular joint surfaces of the elbow. Extensive debridement includes all joints of the elbow. The portal incisions are closed with sutures or Steri-strips.

This description seems to indicate that these codes are "cumulative". In other words, each additional "procedure" increases the code. Thus, 29838 includes extensive debridement AND the synovectomy.

Question: If a complete synovectomy and debridement in four portals is done, should this be billed a) 29836 or b) 29836, 29837-59 or c) 29838 or d) 29838, 29837-59

Note: we initially billed it 29836, 29837-59 and the carrier is bundling 29837 to 29836. Thanks in advance for your response!



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Why modifier 59? Per guidelines modifier does documentation support differant session, differant porcedure or sugery differant site or organ system, separate incision/excision, separate lesion or separate injury not ordinarily encountered or perfermed on same day by same individual. It sounds like 29838 decribes the whole surgery.