August 2003 Bulletin

Coding for shoulder procedures

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Robert H. Haralson III, MD, MBA
Shoulder surgery coding has become more involved and detailed due to performing several procedures in one given operative session.
In 2002, CPT codes were added for many arthroscopic procedures performed in the shoulder region. However, two codes continue to cause some coding dilemmas: 29806 and 29807.

CPT code 29806 - Arthroscopy, shoulder, surgical; capsulorrhaphy.

When this code was added, it became the parent code in the shoulder scope section per CPT guidelines–regarding intended procedures. Thus, the notes under code 29806 can technically pertain to any of the codes in the indented series with the notes indicating for "open procedures, see 23450-23466." With this note appearing directly under CPT code 29806, many thought that this represented an arthroscopic bankart procedure.

CPT code 29807 - Arthroscopy, surgical; repair of a superior labrum anterior/posterior (SLAP) lesion.
The American Medical Association (AMA) publication, CPT Changes 2003, An Insider's View, references the following: "Code 29807 is another new arthroscopic shoulder procedure code intended to be reported when arthroscopic shoulder stabilization and repair of SLAP lesions are performed."
Keep in mind the word "stabilization" can mean many things. However, when it comes to a SLAP lesion repair–even though you may need to go through the capsule to tack the suture/staple–this would normally not be considered a separately reportable procedure.
Since there has been no direct linkage under this code to an open counterpart, more confusion arose. However, under CPT code 23455, it states, "to use 29807 for arthroscopic procedure." This provides a direct link from open bankart to scope bankart.

AAOS Global Service Data book

In the book, AAOS Complete Global Service Data for Orthopaedic Surgery, there is further reference to when coders/physicians can report 29806 and 29807 together during the same operative session.
AAOS Global states, "You can report 29806 with 29807 ONLY if the SLAP lesion repair is Type 2 or Type 4." This indicates that, for the other five types of SLAP lesions, it may not be appropriate to report 29807 along with 29806.

Be clear in operative reports

Surgeons need to be clear in their operative reports of the type of SLAP lesion being repaired. They also need to be clear that two separate lesions are being operated on: SLAP lesions and a capsular defect.

Medicare's National Correct Coding Initiative (NCCI)

The NCCI edits state that 29806 and 29807 are bundled with a status indicator of "1," meaning if an appropriate modifier is used, billing may take place. For an appropriate modifier to be appended, there must be indication of separate site, separate lesion and/or separate session.

Examples:

A surgeon performs an arthroscopic anterior and posterior capsulorrhaphy. How would this be coded? CPT code 29806 would be reported only once. It would be inappropriate to report this code twice because just one capsule is being repaired.
Patient presents with an anterior-inferior capsular defect resulting in instability. Surgeon performs a capsulorrhaphy during which a SLAP 2 lesion is encountered. How would this be coded? Codes 29806 and 29807-59 would be reported. Since two separate lesions were identified, this supports the reporting of the two codes.
Patient presents with a SLAP lesion and surgeon performs arthroscopic SLAP lesion repair. There is reference in the operative report of suture brought up through the capsule. How would this be coded? CPT Code 29807 would be the appropriate code to represent this surgical technique. Since the lesion identified is that of a SLAP, the repair–which includes going through the capsule for stabilization–would not meet the guidelines of a "true" capsulorrhaphy.
When doing a SLAP lesion repair, the lesion is caused by the tendon actually pulling the labrum loose from the capsule. These types of SLAP lesions require repair and this is normally done by placing some sort of suture/anchor/staple through the labrum and into the bone. To do this, the staple has to go through the capsule to get to the bone, but this does not mean that a capsulorrhaphy was done.

Non-glenoid prosthesis procedure

Another shoulder procedure that is causing some difficulty in coding is that of the non-glenoid prosthesis shoulder procedure. In this procedure the humeral shaft is prepared for insertion of the hemiarthroplasty.
The glenoid component is not replaced but it is reamed and formatted to ‘accept' the new humeral head. This procedure is best represented by CPT code 23470, as the AAOS Global Service Data book states that included in the procedure is preparation of humeral canal for prosthetic device. There is no mention of glenoid socket replacement. If the surgeon feels that the work involved on the glenoid component anatomy is greater and/or more difficult because of excess spurs, angle, etc it may be appropriate to append modifier —22. Remember that the documentation must support modifier —22. The AMA/CPT clearly stated in 2001 that coders/physicians should not select a code "that merely approximates" the service being rendered.

Some tips

Double-check the correct usage of the following CPT codes:

Documentation critical

The key issues with correct coding of shoulder procedures, whether arthroscopic or open, will lie in the documentation supplied. Surgeons must clearly state the location, technique, tools and findings as well as what was debrided, repaired, reconstructed or excised.
The Office of the Inspector General states in its Compliance Program for Physicians: "Therefore, one of the most important physician practice compliance issues is the appropriate documentation of diagnosis and treatment. Physician documentation is necessary to determine the appropriate medical treatment for the patient and is the basis for coding and billing determinations."

References:

1. AAOS Complete Global Service Data for Orthopaedic Surgery
2. CPT Changes 2003: An Insider's View, AMA 2003

Margie Scalley Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders' National Advisory Board. She can be reached at vaught@kvalley.com.

Robert H. Haralson III, MD, MBA, is the medical director of Southeastern Orthopaedics in Knoxville, Tenn. He is the CPT advisor for the Academic Orthopaedic Society and has taught courses on the use of AMA Guides, CPT, the use of computers in medicine and disability medicine.