Reimbursements fororthopedic surger-ies under the

Medicare ASC paymentsystem are on the rise. Butif you don’t accuratelyreport and code thesecases, you won’t receivethe maximum reimburse-ment. This is particularlytrue, I’ve found, of com-mon shoulder cases. Let’s review a few of thoseprocedures that, if coded improperly, could meanyou’re leaving money on the table.

Rotator cuff repair and reconstruction CPT code series 23410 to 23420 includes acute orchronic conditions within the CPT verbiage. Theoperative documentation should provide whetherthe patient has an acute versus chronic condition. Ifno indication is provided in the clinical documenta-tion, don’t assume. If an uncertain coder incorrectlyassumes acute, the difference is roughly $150 inunderpayment for a Medicare patient.

While the Medicare reimbursement is the same forCPT codes 23412 and 23420, base your selection onwhether the surgeon repaired (23412) or recon-structed (23420) a chronic tear. AMA guidelines state

that three of the four mus-cles/tendons of the rotatorcuff should be torn, withfurther clarification fromthe AMA stating that CPT23420 is an extreme tear,typically requiringrearrangement of the nor-mal anatomy with occa-sional grafting of biologicalor nonbiological material.

The AMA says that code determination is not nec-essarily based on the number of tendons. Remember,four tendons make up the rotator cuff: supraspinatus(top of humeral head), subscapularis (front ofhumeral head), infraspinatus (back of humeral head)and teres minor (also back of humeral head).

The American Academy of Orthopaedic Surgeonsreiterates that you shouldn’t use CPT 23420 simplyfor a repair of a massive tear but for a reconstruc-tion of a massive tear with significant retractionthat involves extensive releases and mobilization, aswell as fascial or synthetic material when applica-ble, in order to return the tendon to its originalanatomical location. In other words, we aren’t sim-ply suturing and repairing a tendon via anchors andtacks. In addition, three tendons need not be torn tosupport reporting CPT 23420.

Use CPT code series 23410 to 23412 to reportmini open rotator cuff tear repairs, with code selec-tion determined by acute versus chronic conditions.While CPT provides a parenthetical statementunder CPT 29827 (Arthroscopy, shoulder, surgical;with rotator cuff repair) directing the CPT user toreport 23412 for mini open rotator cuff repair, youstill need to determine the final code selectionbased on the acute versus chronic condition. Recallthat CPT code verbiage in 23410 to 23420 is specificto an acute versus chronic condition.

Mini open rotator cuff tear repairs typically don’tinvolve entry into the shoulder joint while the tearcan still be visualized and repaired. When a surgeonperforms an arthroscopic rotator cuff repair, report

CODING & BILLINGCristina Bentin, CCS-P, CPC-H, CMA

Getting Reimbursed for Shoulder Scopes Even the most common procedures can challenge the most experienced coders.

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Rotator Cuff CodesCPT Code Procedure MCR (approx. 2009)

23410 Repair of ruptured $1,264.85musculotendinous cuff open; acute

23412 Repair of ruptured $1,400.39musculotendinous cuff open; chronic

23420 Reconstruction of $1,400.39complete shoulder rotator cuff avulsion, chronic

29827 Arthroscopic surgical $1,342.79shoulder; repair of rotator cuff

CODING & BILLING

CPT 29827 regardless of whether the condition isacute versus chronic.

The operative report should specify an acute ver-sus chronic condition. The technique (open versusarthroscopic) will need to be apparent to include adetailed description of a repair versus reconstruc-tion of the specific tendon(s) or cuff.

Distal claviculectomyExcision of the distal clavicle (approximately 1cm)involving more than a simple shaving of osteophytesat the AC joint is reported separately whether per-formed open or closed, according to the AAOS.

The operative report must indicate the size of thedistalclavicleexci-sion tojustifythe sep-arate

reporting of this code. The facility should verify withcommercial carriers and fiscal intermediaries sincecarrier policy may consider less than 1cm to beinclusive to the main procedure being performed.

Arthroscopic labrum repairs Report CPT 29806 for surgical capsular repairswhen they’re performed arthroscopically. Ratherthan reporting CPT code 29806 for arthroscopicthermal capsulorrhaphy, use the unlisted code29999 versus S2300 for arthroscopic thermal capsu-lorrhaphy, pending carrier guidelines.

Note that many commercial carriers don’t recog-nize S codes. Here’s an opportunity going forward toincorporate S codes and unlisted codes into yourfacility’s new and revised commercial insurance con-tracts. In addition, your facility will want to reviewimplants and Category III codes in order to separate-ly define or carve out these supplies or procedures.

Simply because a labrum is torn and repaired, itdoesn’t automatically warrant reporting 29807 if the

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Distal Claviculectomy CodesCPT Code Procedure23120 Claviculectomy; partial29824 Arthroscopy, shoulder,

surgical; distal claviculectomy

torn labrum isn’t a SLAP (superior labrum fromanterior to posterior) tear. CPT 29807 is specific fora SLAP repair; don’t use it for labral tears that aren’t

SLAPtears.Thesur-geonwilldeter-mine

whether there is a true SLAP tear and also the“type” of SLAP.

Report both 29807 and 29806 per AAOS if thesurgeon performs SLAP Type II or Type IV in addi-tion to capsulorrhaphy for a different indication. Tosimplify, there should be two separate and distinctindications to report the capsular repair and theSLAP tear repair. Verify with commercial carriers asto reporting guidelines for CPT 29807 and 29806during the same session.

Medicare edits bundle CPT code 29807 into CPT29806 at this time, but allows for a modifier if thesurgeon performs SLAP separately and distinctlyfrom the capsulorrhaphy. Use caution when consid-ering the application of a modifier. Remember theterms “separate” and “distinct.” Simply because youcan use a modifier doesn’t imply automatic applica-tion of a modifier with every scenario.

A coder shouldn’t confuse the surgeon’s repair ofthe labrum by attaching it to the capsule as a sepa-rately identifiable capsulorrhaphy. The separatereporting of the capsulorrhaphy is indicated whenthere is a capsular defect unrelated to the labrumtear that in itself also warrants a repair.

Arthroscopic SLAP debridement is reported fromthe arthroscopic shoulder debridement codes pend-ing other debridements performed during the opera-tive session. These debridement codes may be con-sidered inclusive into other surgical procedures per-formed during the same operative session.

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Arthroscopic Labrum Repairs CodesCPT Code Procedure29806 Arthroscopic surgical shoulder;

capsulorrhaphy29807 Arthroscopic surgical shoulder;

repair of SLAP Lesion

CODING & BILLING

SLAP (I, II, III, IV, etc.), documentthe diagnosis for either or both theSLAP and capsulorrhaphy, anddescribe the procedure(s) in detail.

Shoulder debridement CPT 29822 covers limiteddebridement of soft or hard tis-sue. Use it for limited labraldebridement, cuff debridement orthe removal of osteophytes anddegenerative cartilage.

Only use CPT 29823 for exten-sive debridement of soft or hardtissue. It includes, for example,an abrasion chondroplasty of thehumeral head or glenoid andassociated osteophytes, or multi-ple soft tissue structures that aredebrided, such as the labrum,subscapularis and supraspinatus.

Operative documentationshould describe all areas, sites,tendons and lesions debrided orexcised. A sentence stating, “Iperformed an extensive debride-ment” does not justify reporting

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Shouldering the Coding Load Coding common shoulder procedures canchallenge even the most experienced coder.

• The facility should determine both thefiscal intermediary and carrier reimburse-ment guidelines and establish a consistentprotocol for your coder to follow.

• Your coder must be familiar with thevarying coding guidelines, including Medicareedits, American Medical Association guide-lines and the American Academy ofOrthopaedic Surgeons specialty guidelines.

• Your coder must know the ins and outs ofvarying carrier contracts. Some commercialcontracts reimburse similarly to Medicare,some contracts don’t follow Medicare reim-bursement — allowing for more aggressive

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CPT code 29823. What was debrided? How

much was debrided? Did thesurgeon debride from two orthree joint areas/regions? If so,could this debridement standalone, or was it part of anotherprocedure?

Let’s look at an example: Thesurgeon may debride the rotatorcuff in preparation for repairingthe rotator cuff via the arthro-scope. If this were the onlydebridement he performed, you’dconsider this inclusive to thearthroscopic rotator cuff repair,since he performed the debride-ment in preparation for therepair. However, if the surgeonthoroughly describes the debride-

ment of multi-ple areas/sites,such as thelabrumdebridement,abrasionarthroplasty,

biceps tendon debridement and

partial synovectomy, which arenot typically included in a rotatorcuff, then you can feel comfort-able reporting CPT 29823. OSM

Ms. Bentin (cristina@ccmpro.com) is theowner of Coding Compliance Management,a healthcare consulting company based inBaton Rouge, La.

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Arthroscopic Debridement CodesCPT Code Procedure MCR (approx. 2009)

29822 Arthroscopy, shoulder $842.28limited debridement

29823 Arthroscopy, shoulder $1,241.87extensive debridement

coding and reporting — and still others followthe beat of a different drummer.

None of this matters if the documentationin the operative report is lacking in detail.Whether it’s underpayments or denials, boththe facility and the physician will miss reim-bursement opportunities.

— Cristina Bentin, CCS-P, CPC-H, CMA

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