In addition to staying updated on coding changes and billing rules, certified coders in orthopedic medical billing and coding companies have a strong background in anatomy, physiology, related medical terminology, disease processes, and procedures for various body systems. They are also knowledgeable about the rules set forth by commercial insurance companies and Medicare.
Intrinsic disorders of the shoulder, such as injuries and acute or chronic inflammation of the shoulder joint, surrounding ligaments, tendons, or periarticular structures can cause shoulder pain. Reconstructive shoulder surgery is performed to address shoulder instability, assist the patient in regaining function, and stop recurrent dislocations. Surgery is complex because the shoulder is a complex joint.
Here are some important points to note about shoulder surgery documentation, coding and billing:
Shoulder Surgery Documentation: Key Points
Diagnostic specificity: In the current value-based reimbursement system, specificity of the diagnosis is vital. In ICD-10, diagnostic codes require anatomical specificity and laterality as to the area on the body such as: left, right, bilateral. In addition, the 7th digit should be added to the ICD-10 code, as follows: A – Initial encounter, D – subsequent encounter, and S – sequel.
For example, surgery is recommended for severe cases of shoulder bursitis that do not respond to conservative treatments. The ICD-10 codes for shoulder bursitis specify laterality are:
- M75.40 – Unspecified shoulder bursitis
- M75.41 – Bursitis of the shoulder, right shoulder
- M75.42 – Bursitis of the shoulder, left shoulder
- M75.43 – Bursitis of the shoulder, bilateral
- M71.20 – Other specified bursitis, unspecified shoulder
- M71.21 – Other specified bursitis, right shoulder
- M71.22 – Other specified bursitis, left shoulder
- M71.23 – Other specified bursitis, bilateral shoulder
Differences in Centers for Medicare and Medicaid Services (CMS) and the American Academy of Orthopedic Surgeons (AAOS) guidelines: While CMS looks upon the shoulder as single anatomic region, AAOS regards the glenohumeral joint, the acromioclavicular (AC) joint, and the subacromial bursa as separate anatomic areas. Expert medical coding and billing service providers are knowledgeable about these differences and will help physicians submit claims based on payers’ specific rules.
Here are some examples:
Suppose a right arthroscopic rotator cuff repair is performed with a distal claviculectomy, acromioplasty, and debridement of the labrum. The surgeon performed a subacromial decompression and 1 cm is removed from the distal clavicle. In this case, the tendency would be to report the following CPT codes:
- 29827 RT: Arthroscopy, shoulder, surgical; with rotator cuff repair RT side
- 29824 RT: Arthroscopy, shoulder, surgical distal claviculectomy including distal articular space surface (Mumford procedure)
- +29826 RT: Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty with coracoacrmial ligament (arch) release, when performed, and
- 29822 RT- 59: Arthroscopy shoulder surgical; debridement limited distinct procedural service
However, the challenge is that, according to National Correct Coding Initiative (NCCI) edits, 29822 bundles into 29827 and 29824; moreover, as this is the same shoulder, using a modifier to bypass the bundling edit is inappropriate.
- Report 29824 if the service was performed on the shoulder arthroscopically, performed on the distal clavicle, and approximately 1 cm was removed from the distal clavicle.
- Report 29822, limited debridement, if: a 1 cm space was created by removing 7 mm from the distal clavicle and 3 mm from the acromion as the documentation does not meet the minimum requirements for the distal claviculectomy or the acromioplasty.
- Report 29822 and 29826, if the 3 mm removed from the acromion is a true acromioplasty, which is achieved by converting the acromion to a type I morphology with a subacromial decompression. The 7 mm does not meet the requirements of the claviculectomy and documentation must support both services. 29826, arthroscopic subacromial decompression procedure cannot be billed for Medicare cases, because Medicare considers it as an “add-on code” which is a “packaged procedure” and therefore not separately payable.
Billing for “mini-open” operations that progress to full open procedures:
Sometimes an arthroscopic procedure starts out that way, but if the surgeon makes an incision and finishes it as an open procedure, it becomes a “mini-open procedure.” In this instance, only the open procedure requires coding and billing to be completed
Bankart Procedure: Arthroscopic Bankart repair is reported using CPT code 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy).A report (February 2022) in the Journal of POSNA answered the query: “If both an arthroscopic Bankart and SLAP repair are performed, are these codes separately reportable?” The report noted:
- Per CPT guidelines, arthroscopic Bankart and SLAP repair are defined by codes 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion).
- Under AAOS global service guidelines, both codes are reportable with appropriate supporting diagnoses. But NCCI edits and guidelines restrict reporting both of these codes in the same shoulder during a single operative session.
- Useincreased procedural services modifier -22 when the posterior labrum is additionally repaired. The operative report should support the use of this modifier by documenting the reason for increased intensity, time, technical difficulty of the procedure, severity of the patient’s condition, and/or physical and mental effort required.
Get Expert Medical Coding Guidance
These are just a few examples of the intricacies involved in shoulder surgery billing and coding. Being informed about documentation guidelines is essential to ensure correct coding of shoulder procedures, which in turn ensures accurate claim submission and proper reimbursement. This is much easier with medical coding outsourcing to an experienced service provider. Coders and billers in reliable medical coding companies stay up to date with payer policies and requirements as well as CMS, AMA, and AAOS guidelines to ensure proper coding for orthopedic surgery.
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