4 Shoulder Surgery Coding Challenges

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John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates in Tampa, Fla., reviews four coding challenges for orthopedic shoulder procedures and provides solutions, based on comments from sources such as the AMA and AAOS.

1. During an arthroscopic rotator cuff repair, the surgeon made an additional incision or portal site to repair the subscapularis tendon. How should this be reported?

The additional incision or portal site is not reported separately. It is considered an inclusive component of CPT code 29827, "arthroscopy, shoulder, surgical; with rotator cuff repair." This code represents the repair of one, two or three tendons and the number of portals made does not alter the use of this particular code. When another portal is required to repair the subscapularis tendon, it is considered an inclusive component of the procedure.

2. How do I report a superior labrum from anterior to posterior (SLAP) lesion and capsule repair?

You can report two CPT codes — 29806 and 29807 — only if the SLAP lesion repair is Type 2 or Type 4, according to the AAOS Global [Service Data guidelines]. That is, you must have two separate problems: a capsular defect, not caused by SLAP, and a SLAP tear. Documentation should support the type of SLAP lesion being repaired.

3. What is the correct usage of CPT code 23420, "reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)"?

CPT code 23420 is intended to identify an old tear. "This type of extreme tear usually requires rearrangement of the normal anatomy and sometimes grafting with either biological or nonbiological material for repair," according to the CPT Assistant, Oct. 2005, Volume 15, Issue 10, pages 23-24. AAOS also states: "If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of CPT code 23420. If fascia or synthetic material is required, CPT code 23420 also is appropriate. If a tendon transfer was performed, code 23397-59 would be used in addition to CPT code 23420."

4. In rotator cuff reconstructions, must there be major muscles torn or avulsed to use the 23420 code?

Note that the official description of CPT code 23420 cites "reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)." This means you can have a cuff avulsion where the supraspinatus and the infraspinatus muscles are torn so severely that reconstruction is necessary to bring the cuff back up into anatomic location. Since shoulder injuries and RCT can vary from patient to patient, the orthopedic surgeon needs to document the extent of the injury and if it is a repair rather than a reconstruction. A reconstruction would involve more than just anchors and tacks.

Mr. Bishop (BISHOPJF@aol.com) has been an active surgical physician assistant for more than 35 years. He has been the president and CEO of Bishop & Associates, a surgical, medical and coding/reimbursement consulting company, for nine years.

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