Shoulder coding: Questions, answers and clarifications
By M. Bradford Henley, MD; William R. Beach, MD; Blair C. Filler, MD; Melvin M. Friedman, MD; Richard J. Friedman, MD; Frank R. Voss, MD; and Margie Scalley Vaught
The AAOS Coding, Coverage and Reimbursement Committee responds to a number of recent questions on coding shoulder procedures.
Q. What is the difference between codes 29820, 29821, 29822 and 29823? Does the shoulder have separate compartments?
A. The AAOS Coding, Coverage and Reimbursement Committee recognizes three “areas” or “regions” of the shoulder: the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space. These “areas” are clearly separate; procedures done in one area should not influence coding in a different area.
Generally, code 29820 is used for a partial synovectomy, similar to the separate procedure code. If only a diagnostic arthroscopy is performed, and some synovium is resected for visualization, only a diagnostic arthroscopy can be reported. If a partial synovectomy is medically necessary (for a redundant synovial plica or limited synovitis), code 20980 should be reported.
Code 29821 should be used for a complete synovectomy for a synovitic disease, such as rheumatoid arthritis or pigmented villonodular synovitis, with removal of the entire intra-articular synovium.
Code 29822 covers limited debridement of soft or hard tissue and should be used for limited labral debridement, cuff debridement or the removal of degenerative cartilage and osteophytes.
Code 29823 should be used only for extensive debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis and supraspinatus.
Infected total joint
Q. How do you bill and report for an infected total joint when you have already removed the hardware and gone through the course of antibiotics and the patient is now ready for the new prosthesis to be inserted? Would this still be a revision code?
A. Technically, there is no hardware within the joint, so this is not a revision. The ICD-9 Coding Clinic addressed this issue in Vol. 8, No. 2, Second Quarter, 1991, as follows:
“Q. When a patient is admitted for revision of a hip arthroplasty, with the prosthesis having been removed previously due to infection, should the code for revision or the code for replacement be assigned? The orthopaedic surgeon states that this would be considered a revision, no matter how much time elapses between the removal and the subsequent replacement.
“A. No, this should not be coded as a revision but as a replacement. The diagnosis for the first admission would be coded 996.66—Infection and inflammatory reaction due to internal joint prosthesis, and the procedure code would be removal of prosthesis of hip. For the second admission, the principal diagnosis code would be 736.39—Other acquired deformity of the hip, and the procedure code would be coded as a hip replacement.”
If there is an implanted antibiotic impregnated “spacer,” and not a true prosthesis (even if in the shape of a prosthesis), the procedure should be coded as “Removal of a nonbiodegradable drug delivery implant” (11982-51) with an arthroplasty code (not a revision arthroplasty code).
Reverse total shoulder arthroplasty
Q. What CPT code would you report when performing a reversal total shoulder arthroplasty?
A. CPT will, at times, have one code that covers a particular procedure such as arthroplasty. Different techniques are then developed to either enhance or strengthen the procedure. But when it comes to coding, the procedure is still considered an arthroplasty. If the surgeon is able to document more extensive work or unusual circumstances such as an altered surgical field from prior injury, surgery or extensive scarring, modifier –22 may be considered when assigning 23472.
Lateral epicondylar release
Q. Some of us have started doing a modified lateral epicondylar release using a Topaz thermal cautery device. Would we be able to report 25290—Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon; 24310—Tenotomy, open, elbow to shoulder, each tendon; and 24356—Fasciotomy, lateral or medial (e.g., tennis elbow or epicondylitis), with partial ostectomy?
A. This is an extensor origin detachment for lateral epicondylitis, 24351. The method of tissue dissection or cutting is not relevant. It is the physician’s work—not the tool—that is being reimbursed.
Q. Has CMS deleted the Synvisc medication HCPCS code for 2006? We are getting denials for J7320.
A. Your Medicare carrier isn’t up-to-date on the changes. Point them to Pub. 100-04 Transmittal 786 - January 2006 Update of the Hospital Outpatient Prospective Payment System (OPPS): Summary of Payment Policy Changes, OPPS PRICER Logic Changes, and Instructions for Updating the Outpatient Provider Specific File (OPSF). It reads:
“c. Coding Changes for Sodium Hyaluronan Products
“The following HCPCS codes will be effective under the OPPS for sodium hyaluronan products beginning 1/1/06: C9220 (sodium hyaluronate per 30 mg dose, for intra-articular injection), J7317 (sodium hyaluronate per 20 to 25 mg dose for intra-articular injection), and J7320 (Hylan G-F 20, 16 mg, for intra-articular injection).”
The topic was also covered in the Federal Register, December 23, 2005:
“On page 68643 and in Addendum B, we erroneously referred to the creation of a code by the National HCPCS Panel, specifically the creation of HCPCS code J7318. This was incorrect as this code was not created by the National HCPCS Panel. Our error was discovered after publication, and we are taking this opportunity to revise Addendum B to reflect the CY 2006 payment for Sodium Hyaluronate products using HCPCS codes J7317 and J7320, as originally included in the CY 2006 OPPS proposed rule.”
Finally, a recent Part B News Briefs reported: “CMS will not replace J7317 (sodium hyaluronate inj., 20-25 mg.) with new 1 mg code J7318 for sodium hyaluronate in 2006 after all. The agency announced the switch in the 2006 final fee schedule and in its original list of 2006 HCPCS codes. We then reported the change in our code replacement Part B News Special Report on Dec. 5. CMS since has backed off of the change and you will continue to bill J7317 in 2006. The 2006 HCPCS codes were updated by CMS to reflect this change.”
M. Bradford Henley, MD, is chair of the AAOS Coding, Coverage and Reimbursement Committee; William R. Beach, MD; Blair C. Filler, MD; Melvin M. Friedman, MD; Richard J. Friedman, MD; and Frank R. Voss, MD, are members of the committee.
Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist and BONES member who has served on the National Advisory Board for the American Academy of Professional Coders. She can be reached at firstname.lastname@example.org