Coding Case Study: Meet the Challenge of Multicode Shoulder Surgeries

Published: 27th March 2012
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Complicated arthroscopic shoulder surgeries often result in multiple surgical procedures being performed in the same session. Where it might be easiest simply to match the procedure to the appropriate code, coders need to be aware not only of the codes that best describe what was done, but also what procedures are bundled into other codes.

A Complicated Surgery

Southeast Orthopaedic Institute, a solo-practice orthopedic surgery center in Atlanta, performs surgeries mostly on knees and shoulders. For billing coordinator Peggy Flores, that amounts to numerous coding challenges for the different surgeries performed. The shoulder surgeries in particular are difficult, says Flores, because there are often so many different procedures done at the same time. My main concern is that I might accidentally unbundle the procedures, which in this case seems to be easy to do.

Flores operative report illustrates one of the challenging surgeries. The preoperative diagnosis was for:

  1. Rotator cuff tear of the left shoulder (840.4)

  2. Labral tear of the left shoulder. (840.8)

The operation consisted of seven different procedures:

  1. Arthroscopic labral debridement and repair;

  2. Arthroscopic chondroplasty, glenoid;

  3. Repair of middle glenohumeral ligament with

  4. Open acromioplasty with coracoacromial ligament

  5. Limited distal clavicle resection;

  6. Release of coracohumeral ligament; and

  7. Repair of rotator cuff tear.

A Process of Elimination

With a multiprocedure operation like this one, the best way to proceed, according to Heidi Stout, CPC, coding and reimbursement specialist at University Orthopaedic Associates, a multispecialty orthopedic practice in New Brunswick, N.J., is to find the CPT codes that describe each component of the procedure in this case seven codes. After that, says Stout, you can determine which of the codes can be reported together and which should be bundled into other codes, meaning they are considered part of another procedure and therefore not billable separately. Stout, along with James Guerra, MD, VACS, shoulder specialist of Collier Sports Medicine and Orthopedic Center, in Naples, Fla., helps Flores code the surgery.

1. Arthroscopic labral debridement and repair. Stout and Guerra concur that this is essentially an open capsulorraphy and Bankart repair (23455, capsulorraphy, anterior, with labral repair [e.g., Bankart procedure]) done arthroscopically instead of as an open procedure. There is no CPT code that describes this procedure; therefore you should report the unlisted arthroscopy code 29909 (unlisted procedure, arthroscopy). When reporting an unlisted procedure code, supporting documentation must be submitted with the claim. Stout suggests that you submit the operative report along with a letter that describes the procedure in laymans terms and includes information about the time, expertise and special equipment required to provide the service.

2. Arthroscopic chondroplasty, glenoid. When performing a Bankart repair or labral repair, it is necessary to debride fibrocartilaginous tissue off the glenoid in preparation for the repair. Both experts agree that this is a bundled service. This is an integral part of the labral repair, says Stout, and should not be coded separately.

3. Repair of middle glenohumeral ligament with ultrasound. According to Guerra, this is the capsulorraphy aspect of the Bankart repair and an integral part of the first procedure, and should not be billed separately.

4. Open acromioplasty with coracoacromial ligament resection. Code 23415 (coracoacromial ligament release, with or without acromioplasty) describes this procedure. But Stout and Guerra both point out that when performed with an RTC (rotator cuff repair), it is bundled with that code and should not be reported separately.

5. Limited distal clavicle resection. Stout says that 23120 (claviculectomy; partial) can be reported for this procedure. Guerra feels that 23120-52 (claviculectomy; partial; reduced services) should be reported instead. But even this is pushing it, says Guerra. Either a complete distal clavicle resection was performed (Mumford procedure) and it should be billed as a 23120 with modifier -51 (multiple procedures), or only a partial was performed and it should be billed as part of the acromioplasty. You can try and bill for 23120-52-51 and see what the carrier says.

6. Release of coracohumeral ligament. If a stand-alone procedure, this could be reported with 23415, but here it is part of a rotator cuff repair and should not be reported separately.

7. Repair of rotator cuff. CPT provides three rotator cuff repair codes. You most likely will need to check with the surgeon to verify which code is appropriate for this surgical case. Use 23410 (repair of ruptured musculotendinous cuff [e.g., rotator cuff]; acute) for repair of an acute rupture of the rotator cuff. Code 23412 (repair of ruptured musculotendinous cuff [e.g., rotator cuff]; chronic) is for repair of a chronic rupture of the rotator cuff. Code 23420 (reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]), describes a reconstruction for a chronic complete avulsion of the rotator cuff.

Using this process of elimination, Stout and Guerra determined that the claim form would read as follows:

29909 (procedures 1, 2 and 3)
23410-51 or 23412-51 or 23420-51 (procedures 4, 6
and 7)
23120-52-51 (procedure 5)

Unlisted Codes Need Extra Documentation

Flores says that the arthroscopic surgeries of the shoulder are especially problematic from a coding perspective. It gets a little crazy, she says, because we have to use the 29909 code so often in virtually all of the doctors shoulder surgeries. For Flores, this means submitting extra documentation. We write a thorough description of what was done, why we had to use the unlisted code, etc. The insurance companies generally discourage us from using unlisted codes instead of other procedural codes, so they want to make sure that we have no other coding options. She reports that once the procedure and coding decisions are spelled out explicitly to the carrier, the claim usually gets paid.

The insurance companies bundling of codes poses a problem as well. According to Flores, many carriers have computerized systems for processing claims that do not necessarily coincide with accepted standards for orthopedic coding. They have a tendency to say procedures are bundled when theyre not, says Flores. The computer programs are designed to bundle as much as possible to save money for the carrier, but they are not always correct.

Flores uses the AAOS (American Academy of Orthopedic Surgeons) Global Service Data for Orthopaedic Surgery as a weapon against carriers bundling of codes. The AAOS guide clearly states what procedures are included with others and which can be billed separately. She routinely copies the appropriate page out of the guide and submits it with her appeal of a denied claim. Usually I dont send the information in until the appeal, says Flores, unless I see a red flag that I know will be a problem with the carrier. Then I send the AAOS data at the outset. Few insurers will argue once youve provided them with proof of a legitimate claim."

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