Wiki NCCI edits for Shoulder Coding

[Soms4]

I have been told by an auditing company that you can put a 59 on a shoulder code to bypass an NCCI edit as long as there is medical necessity. For example shoulder repair 29827, debridment of labrum 29822, and synovectomy 29820. Since there was a diagnosis code to meet medical necessity for each procedure perfmormed we were told to code as 29827, 29822 59, 29820 59. However from information I have for NCCI edits their defintion of using the 59 is it should only be used if it is a different antatomic site or different patient encounter. Also that different diagnoses are not adequate criteria for use of modifier 59.

Does anyone have input on the correct way to code the above per NCCI edits? Thank you !

 

[debwoods65]

29827 ARTHROSCOP ROTATOR CUFF REPR
No bundling issues exist
29822 SHOULDER ARTHROSCOPY/SURGERY
Code 29822 is a component of Column 1 code 29827 but a modifier is allowed in order to differentiate between the services provided.
29820 SHOULDER ARTHROSCOPY/SURGERY
Code 29820 is a component of Column 1 code 29827 but a modifier is allowed in order to differentiate between the services provided.
Code 29820 is a component of Column 1 code 29822 but a modifier is allowed in order to differentiate between the services provided.

It is my understanding and the practice of our office that we do not bill seperately for arthroscopic shoulder procedures unless they were performed in a seperate area of the shoulder when CCI states that a modifier is allowed. Just because a modifier is allowed does not mean it is appropriate. As I understand it, there are 2 "seperate" areas on the shoulder (similar to the 3 compartments in the knee). AAPC has offered a webinar in the past that was quite helpful with this issue and may be worth looking into. Hope this helps.

 

[mmpratt]

From Medicare NCCI edits, Chapter I, Section E:

"From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site."

This is what our office uses as a guide to shoulder procedures. It is also what our payers reference in denials of multiple CPT codes billed with -59 even though the additional procedures are clearly addressed in the op report with separate diagnoses.

Getting paid for all the work a surgeon does in the shoulder area is a nightmare.