Shoulder the Burden of CCI Edits With These Shoulder Arthroscopy Rules

Tue, Apr 12, 2016 --

Coding Updates

shoulder arthroscopy cpt code, shoulder cpt codes, cpt for shoulder arthroscopy, right shoulder arthroscopy, shoulder arthroscopy

When you’re reporting shoulder joint procedures, watch out for modifier 59 (Distinct procedural service). Let’s take a look at an example straight out of CMS’s Modifier 59 Article.

The article offers an example of 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) and 29820 (… synovectomy, partial) performed during the same session. Code 29820 is a column 2 code in a Correct Coding Initiative (CCI) edit pair with 29827. The bundle has a modifier indicator of 1, meaning that you may use a modifier to override the edit when appropriate.

But which modifier? And when is overriding the edit appropriate?

According to the article, “the shoulder is a single anatomic structure.” Consequently, you should not override the edit when the procedures occur on the same shoulder.

You may report both codes for the same session only if the procedures take place on different shoulders. The article advises use of anatomic modifiers RT (Right side) and LT (Left side) to tell the story of which shoulder underwent which procedure, rather than using modifier 59.

Watch Out! Other Payers May Have Other Advice

If you’re billing a payer other than Medicare for these services, make sure you check with that payer before you drop the bill, as insurers differ on the way they handle these codes.

Bonus Tip: Check Out +29826 History

Just for fun, let’s take a look at another shoulder code, +29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e., arch] release, when performed [List separately in addition to code for primary procedure]).

According to CPT® Assistant, the appropriate primary codes for add-on code +29826 include 29820 and 29827, among several others. But why is this an add-on code instead of a stand-alone procedure?

The March 2015 CPT® publication explains that in 2011, the AMA/Specialty Society RVS Update Committee (RUC) Relativity Assessment Workgroup recommended converting 29826 to an add-on code because the committee found the code had been billed a vast majority of the time with other shoulder arthroscopic repair codes. The add-on code approach was preferred to dealing with multiple procedure reduction rules.

The AMA convenes the RUC committee each year to rank procedures by how much time, skill, and mental work they require, creating the “physician work” portion of relative value units (RVUs) for CPT® codes.

How About You?

Has your practice had success navigating shoulder arthroscopy surgery? Let us know in the comment box below.

Get the Scoop on 2016 Shoulder Procedure Coding, CCI Guidelines, and More!

Join Margie Vaught, CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR, in a one-hour AudioEducator webinar that will help you navigate the many challenges with shoulder arthroscopy procedure coding! You’ll get clarification on coding for shoulder issues like 23415 versus 23130, surgical repair of the pectoralis, and nonunion repair of the clavicle. You’ll take a look at payer denial and documentation issues, and understand when modifier 59 is appropriate from both a CPT® and CCI standpoint. You’ll learn to make your surgeons understand the importance of documentation, and you’ll find out why payers are going crazy over wording. Don’t wait to register — the webinar is today, April 12, at 1 p.m. Eastern time. But don’t worry — if you miss the live event, you can order a DVD or transcript instead. Register today!

About 

Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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