Wiki Need help with shoulder surgery

cmasters

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Hello, I was needing help knowing if the 29821 and 29825 based on documentation is appropriate to bill. I am new to Ortho coding and struggling to understand the shoulder surgeries.
Thank you for you help
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When it comes to the shoulder knowing the anatomy is 100%. Without knowing the anatomy, you cannot code shoulders. I have not read the op note, but assume that these codes are correct and put them in Encoder or Codify and see where the edits direct you.
 
When it comes to the shoulder knowing the anatomy is 100%. Without knowing the anatomy, you cannot code shoulders. I have not read the op note, but assume that these codes are correct and put them in Encoder or Codify and see where the edits direct you.
I totally agree with you on the anatomy part, I am working on that part. I did put in codify and they have NCCI edits on them but can be used with modifier.
 
In my opinion, for new folks, shoulder scopes are the most confusing and difficult to code aside from hip scopes or big, multi-procedure knee scopes. Agree, anatomy is the basis for all coding. You would also want to understand NCCI edits, the NCCI manual and have an AAOS Complete Global Service Data book set which is really helpful. CPT Assistant is also necessary. AAOS/Zupko conferences and webinars are also helpful. Especially if you are only going to be coding orthopedics.

The best thing to do is look at the header and jot down what you think the codes are per each procedure. Then go to the body of the op note and find that the procedures are listed and described in detail. Use a highlighter on paper if you can, if not use scratch paper (or electronically). Then you can take those codes and run through NCCI to see what bundles, etc. If you find something stated in the body is not in the header or vice versa, it may be query time.

On this note, in the header, you would have noted 1. 29821 (complete synovectomy), 2. 29825 (lysis), 3. 29828 (tenodesis). The body of the note describes all three. Paragraph #3 has debridement of the labrum and rotator cuff (supraspinatus and infraspinatus not called out in the header - 29822) and synovectomy (29821). Paragraph #4 has the lysis (29825) and biceps tenodesis (29828).

From your code choices listed above, you are missing the biceps tenodesis which is the main procedure here - 29828. In this case if you were to run these through NCCI, you can only report the 29828 because the other procedures bundle into that. While it says a modifier "may be allowed" I personally would not append 59 to the 29821 or 29825. Generally, lysis, synovectomy, and limited debridement are always going to bundle into the "greater" procedure. Further, 29825 bundles into 29821 also. I guess some would argue on that and append a 59 to 29821 and 29825. I don't have a current AAOS book but my 2020 one says those are not included in the global of the others, but it goes against the NCCI manual (see below). If it was Work Comp I would report it. You also have to consider if the payer is following CMS or not.

"4. With 3 exceptions (which are described in Chapter IV, Section E (Arthroscopy), Subsection 7), an NCCI PTP edit code pair consisting of 2 codes describing 2 shoulder arthroscopy procedures shall not be bypassed with an NCCI PTP-associated modifier when the 2 procedures are performed on the ipsilateral shoulder. This type of edit may be bypassed with an NCCI PTP-associated modifier only if the 2 procedures are performed on contralateral shoulders."
"7. Shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than the other procedure. With 3 exceptions, shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder than the other procedure. CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder."

Don't get discouraged, shoulder scopes are hard.
 
In my opinion, for new folks, shoulder scopes are the most confusing and difficult to code aside from hip scopes or big, multi-procedure knee scopes. Agree, anatomy is the basis for all coding. You would also want to understand NCCI edits, the NCCI manual and have an AAOS Complete Global Service Data book set which is really helpful. CPT Assistant is also necessary. AAOS/Zupko conferences and webinars are also helpful. Especially if you are only going to be coding orthopedics.

The best thing to do is look at the header and jot down what you think the codes are per each procedure. Then go to the body of the op note and find that the procedures are listed and described in detail. Use a highlighter on paper if you can, if not use scratch paper (or electronically). Then you can take those codes and run through NCCI to see what bundles, etc. If you find something stated in the body is not in the header or vice versa, it may be query time.

On this note, in the header, you would have noted 1. 29821 (complete synovectomy), 2. 29825 (lysis), 3. 29828 (tenodesis). The body of the note describes all three. Paragraph #3 has debridement of the labrum and rotator cuff (supraspinatus and infraspinatus not called out in the header - 29822) and synovectomy (29821). Paragraph #4 has the lysis (29825) and biceps tenodesis (29828).

From your code choices listed above, you are missing the biceps tenodesis which is the main procedure here - 29828. In this case if you were to run these through NCCI, you can only report the 29828 because the other procedures bundle into that. While it says a modifier "may be allowed" I personally would not append 59 to the 29821 or 29825. Generally, lysis, synovectomy, and limited debridement are always going to bundle into the "greater" procedure. Further, 29825 bundles into 29821 also. I guess some would argue on that and append a 59 to 29821 and 29825. I don't have a current AAOS book but my 2020 one says those are not included in the global of the others, but it goes against the NCCI manual (see below). If it was Work Comp I would report it. You also have to consider if the payer is following CMS or not.

"4. With 3 exceptions (which are described in Chapter IV, Section E (Arthroscopy), Subsection 7), an NCCI PTP edit code pair consisting of 2 codes describing 2 shoulder arthroscopy procedures shall not be bypassed with an NCCI PTP-associated modifier when the 2 procedures are performed on the ipsilateral shoulder. This type of edit may be bypassed with an NCCI PTP-associated modifier only if the 2 procedures are performed on contralateral shoulders."
"7. Shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than the other procedure. With 3 exceptions, shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder than the other procedure. CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder."

Don't get discouraged, shoulder scopes are hard.
Thank you so much for this info. This helps tremendously. Also I have looked for some webinars but do not see any directly relating. Any ideas?
 
Thank you so much for this info. This helps tremendously. Also I have looked for some webinars but do not see any directly relating. Any ideas?
If the surgeon stays arthroscopic, it makes things much easier. The only arthroscopic codes that hit an edit with shoulders are 29806 & 29807. Before any suture is placed (to hold down a tendon or other structures) the area where the suture is placed will always be debrided. So if debridement is performed in preparation for a procedure, that debridement is not included with 29822 or 29823. Code 29822 cannot be billed with any arthroscopic procedure and 29823 must billed with 29824, 29827 or 29828 which Amy has pointed out. If the surgeon stays arthroscopic it really cuts down on the edit conflicts. Your right, there are no webinars shoulder related. Years ago I paid $220 for a seminar, and was provided the very "basics" of shoulder coding. Never do that again. Once you get the anatomy down and keep a few things in mind shoulders become much easier.
 
This one may help. I have not seen this specific one but I have participated with this group before and it was good.

I agree, it takes learning time, understanding anatomy, reading the NCCI manual and understanding the edits, the AAOS Complete Global Service Data books are really helpful to understand what is included/excluded. However, even though it may be in there the payer may not agree. Watching instructional surgery videos where the surgeon is performing these and explaining what they are doing as they go is helpful. Also, just because they list a bunch of different procedures in the header doesn't mean they will all be reportable. That's why the "outline" method helps to do by writing all the codes out, looking for them in the body but then running through an edit checker. It's up to the coder to decide what to unbundle (or not).

If you are doing more than just shoulders and other orthopedic cases, the Zupko seminars are really great. They usually heavily cover shoulders during the procedure/surgery coding day. And, you leave with resource books to take home.
 
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