Question Shoulder arthroscopy bundling

dchenkin

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I cannot seem to square what I see as a contradiction in the NCCI edits with respect to shoulder arthroscopy. According to the change in the policy manual in 2017, “With three 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.” Those three exceptions are 29824, 29827, and 29828. But the exception is only valid if the debridement is done in a separate area of the shoulder from where those procedures were done. Outside of those three exceptions, according to what appears to be the plain language of the manual, if any other shoulder procedure is done along with 29823 than the debridement bundles into the other code. Therefore, based on this it sure seems that if 29821 and 29823 are performed on the same shoulder than 29823 bundles into 29821. Alas, the NCCI PTP spreadsheet tells a different story. In the latest version of the PTP edits spreadsheet, 29823 is the column 1 code and 29821 is the column 2 code, and the rationale is “More extensive procedure”. So, which is it? Does 29823 always bundle as the policy manual says (except for the three exceptions) or does 29821 and the other column 2 codes bundle into 29823? What am I missing?
 

daedolos

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29823 would be considered the Column 1 Primary service and 29821 would be Column 2 Secondary and a modifier is allowed to override this relationship per any valid scenarios that you've gone over in your post.

Peace
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Look for the the Modifiers column in the NCCI Table of Edits for PTP-Practitioners. These edits show how pairs are related.

0 = Not allowed
1 = Allowed
9 = Not Applicable

 

dchenkin

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Thanks. I get that. I would always bundle 29821 into 29823 when reported on the same shoulder. Then I had a recent discussion with a nurse/coder friend and she said that the language in the Arthroscopy section of the policy manual says that 29823 should be bundled. And when I reread the language I can see why she says that. That is really my problem. Do you disagree that there appears to be a conflict between the manual and the PTP table?
 

Orthocoderpgu

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Thanks. I get that. I would always bundle 29821 into 29823 when reported on the same shoulder. Then I had a recent discussion with a nurse/coder friend and she said that the language in the Arthroscopy section of the policy manual says that 29823 should be bundled. And when I reread the language I can see why she says that. That is really my problem. Do you disagree that there appears to be a conflict between the manual and the PTP table?
In 2017 CMS changed the surgical policy manual to indicate that the shoulder is "one anatomical" location. Due to that decision you cannot bill any shoulder procedures that hit an edit, period. Now remember, this is a CMS guideline. So it would apply to CMS, Advantage plans and any other insurance that is following CMS rules. Most insurance follows CMS.

You are correct, 29823 can only be billed with 29824, 29827 & 29828. Other than that if it hits an edit, it probably can't be billed.
 

Orthocoderpgu

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Interesting take. Let me mull that over for a bit. Thanks.
This information can be found in the the CMS Surgical Policy Manual and previous issues of HBM.

The President of AAOS met with CMS officials every year and tried to get them to understand that debridement itself was an interventional procedure and not always performed as the start of a restorative procedure especially when a suture is going to be anchored such as 29806 or 29827. For years if your surgeon debrided a Type I SLAP lesion all the insurance companies would deny it as "Bundled with 29827" for example. The debridement of a SLAP lesion is done on the labral tissue that has pulled off the glenoid bone. The debridement performed to anchor a suture for 29827 is done on the humeral head. These procedures are not at all related but were always denied as being bundled. In 2017 CMS threw us a bone and at least allowed extensive debridement (29823) with 29824, 29827 & 29828. Many private payers are following CMS and paying for 29823, but not all are. So...
 

dchenkin

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I swear I must have a mental block about this issue. While I am aware of some of the history regarding the change that occurred in 2017 I cannot seem to reconcile what it says in the in the CCI Policy Manual and the table of edits. I have a case where a provider billed 29823, 29821, 29826, 29819, and 20610. And for the sake of discussion let us assume that CMS rules over all. Also all the work was done to the same shoulder. 20610 clearly bundles as it was used to inject post-operative pain control meds. With the exception of 29826, 29821 and 29819 are column 2 codes to 29823. Column F has a 1 and the rationale is "More extensive procedure". In fact the edit where 29823 is column 2 to 29821 was removed as of 12312016 and the edit that put 29821 in column 2 for 29823 was added 01012017. For the moment let us forget what it says in the Arthroscopy section of the Policy Manual. The way I read the edit table is that 29823 is the more extensive procedure and the synovectomy and the removal of loose bodies is bundled into the debridement code when all the work is done on the same shoulder. Am I correct so far?

I then double check myself and read what the manual has to say and I come across the sentence, “With three 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.” That says to me that the synovectomy or the removal of loose bodies subsumes the debridement and I cannot bill the debridement. Am I reading the manual correctly?

If I have read the manual correctly and if I analyzed the table correctly it appears that one of them is wrong. Unless of course I am wrong. I would greatly appreciate it if you could really dumb this one down for me as, like I said at the beginning I must have a mental block. Thanks.
 

Orthocoderpgu

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I think it's the time line that is messing with your head. Keep in mind that all of these policies were implemented at different times.

Nothing is going to over-ride the CMS NCCI Surgical Policy manual. Or the General Policy manual for that matter.

Knowing that you can't bill 29823 because it's not paired with 29824, 29827 or 29828.

You can exclude 20610 because that will hit an edit. Frequently injections are given after the surgical procedure to help reduce the pain.

Take the codes that you have left, if they hit an edit, remove the code with the lowest RVU.

Now, let's talk about the "surgeon's point of view" because it's important. They know that for every procedure that they perform that there is a CPT code that can be used to bill it. So it's easy for them just to write down all the CPT codes after a surgery and they usually think that all of them are allowed to be billed. That's where coders come in and why we are so important.
 

dchenkin

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Your last paragraph is spot on. The advise regarding the RVU makes sense. Thanks. However, I would warn you about getting to deep into my head. :)
 
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