June 1999 Bulletin

Coders must put 'why' into record

Hemiarthroplasty needs more information than just 23470

By Margie Scalley Vaught, CPC

Many operative reports will state under the procedure performed: Hemiarthroplasty, Right Shoulder. That is what the physician performed, so why do the coders at the facility and the physician's office need to know more?

For hemiarthroplasty of the shoulder, there needs to be documentation as to why this procedure was performed. There are three choices that are listed in the CPT book. The problem is that most coders will choose code 23470. This reads "Arthroplasty, glenhumeral joint; hemiarthroplasty." However, what are the diagnoses that caused the physician to do this type of procedure? Was it because of arthritis (23470), humeral neck fracture (23616) or a bone tumor of the proximal humerus (23222)? If all your hemiarthroplasties of the shoulder are being coded 23470, you may be coding incorrectly.

The Office of the Inspector General looks very closely at what is being coded and if it leads to upcoding, this is considered a false claim. Sufficient information must be documented in the operative note to allow the coder to choose the correct code. If your computer system has only one of the hemiarthroplasty codes available, you probably have another problem. It is very important that all of the choices for coding hemiarthroplasties are included on your software program or fee sheet.

Another tricky area in the shoulder is when a revision of a partial or total arthroplasty needs to be performed. The reason for the procedure needs to be well documented. Let's go through a couple of scenarios.

Your patient had a previous hemiarthroplasty following a humeral neck fracture (23616). Several years later, he returns with complaints of pain and limited movement in the shoulder. On X-ray, it is noted that the glenoid surface shows signs of significant degeneration, but the humeral component was stable without signs of loosening. The decision is made to convert the hemiarthroplasty to a total shoulder arthroplasty.

How would this be coded? Since it has been several years since the original procedure, it would be appropriate to code this conversion as 23472-52. Since there is no code for conversion of a hemiarthroplasty to a total arthroplasty as there is for hips, you would use the total shoulder code with a reduced modifier -52. The reason for -52 reduced services, is that the humeral component was not replaced. The "ball" of the component may be replaced if a modular system was used, but the humeral component itself is not changed.

The amount that you would charge for this should reflect that part of the code that would cover just doing one component (in this case, the glenoid). While it is true that the term "hemiarthroplasty" can mean replacing either part of the joint, code 23470 is for replacing the humeral portion of the joint only. The Academy's Complete Global Service Data for Orthopaedic Surgery states that this procedure includes the preparation of humeral canal for prosthetic device. Another option would be to use 23929, unlisted procedure. I have found that if there is a CPT code that has all the intraoperative services that were performed, with a few that were not done at that session, using that code with modifier -52 represents a more accurate picture than an unlisted procedure. Of course you would need to document what was not done in that code and adjust the value appropriately.

Another patient had a total shoulder performed two years earlier. He was doing fine until he forgot to tell his dentist that he had a total shoulder in place. After having his dental work done, he developed an infection in the shoulder and the total shoulder components needed to be removed along with the nonviable bone. He was treated with a course of IV antibiotics and after adequate treatment (which would still be in the global period) a total shoulder arthroplasty was performed replacing both components.

How would this be coded? First, you would code for removal of the total components, 23332 and removal of the dead infected bone 23174 if indicated. If you are planning at a later date to perform further debridement of the bone and then finally performing the total shoulder arthroplasty, you would code each of the follow-up debridements with a modifier -58 and also attach that modifier to the total shoulder code (23472), letting the insurance carrier know that these were staged procedures during the global period.

As you can see, more and more of the CPT codes need to be diagnoses-linked to accurately code the procedure. If this information is not being provided on the operative note to give a "history" of the indication for surgery, this needs to be done. Avoid using terms that are not used in the CPT codes. It is very confusing and difficult to relay information to coders and insurance carriers if the right terminology is not used. The next time you get ready to perform a shoulder arthroplasty, make sure that you have created a "documentation picture" of the reasons for this procedure.

Margie Scalley Vaught, CPC, is an office manager and coding specialist for Daniel L. Hiersche, MD, an orthopaedic surgeon, Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

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