Shoulder Surgery BillingOne of the main reasons why the coders in established medical coding companies are able to ensure error-free clinical documentation is because they have a strong foundation in anatomy, physiology, related medical terminology, disease processes and procedures for different body systems. They are also knowledgeable about Medicare coding guidelines and those of leading industry associations. This is crucial for orthopedics medical billing and coding.

Shoulder pain may be due to intrinsic disorders of the shoulder, including injuries and acute or chronic inflammation of the shoulder joint, tendons, surrounding ligaments, or periarticular structures. Shoulder pain can also be referred pain. Reconstructive shoulder surgery is performed to address shoulder instability, and help the patient regain function and prevent recurring dislocations. As shoulder is a complex joint, surgery is also complex. Here are some important points to note about shoulder surgery documentation, coding and billing:

  • Diagnostic specificity: In the current value-based reimbursement system, specificity of the diagnosis is vital. In ICD-10, diagnostic codes require anatomical specificity and laterality as to the area on the body such as: left, right, bilateral. In addition, the 7th digit should be added to the ICD-10 code, as follows: A – Initial encounter, D – subsequent encounter, and S – sequel.
  • Differences in Centers for Medicare and Medicaid Services (CMS) and the American Academy of Orthopedic Surgeons (AAOS) guidelines: While CMS looks upon the shoulder as single anatomic region, AAOS regards the glenohumeral joint, the acromioclavicular (AC) joint, and the subacromial bursa as separate anatomic areas. Expert medical coding and billing service providers are knowledgeable about these differences and will help physicians submit claims based on payers’ specific rules. Here are some examples:

    Suppose a right, arthroscopic rotator cuff repair is performed with a distal claviculectomy, acromioplasty, and debridement of the labrum. The surgeon performed a subacromial decompression and 1 cm is removed from the distal clavicle. In this case, the tendency would be to report the following CPT codes:

    • 29827 RT: Arthroscopy, shoulder, surgical; with rotator cuff repair RT side
    • 29824 RT: Arthroscopy, shoulder, surgical distal claviculectomy including distal articular space surface (Mumford procedure)
    • +29826 RT: Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty with coracoacrmial ligament (arch) release, when performed, and
    • 29822 RT- 59: Arthroscopy shoulder surgical; debridement limited distinct procedural service

    However, the challenge is that, according to National Correct Coding Initiative (NCCI) edits, 29822 bundles into 29827 and 29824; moreover, as this is the same shoulder, using a modifier to bypass the bundling edit is inappropriate.

    • Report 29824 if the service was performed on the shoulder arthroscopically, performed on the distal clavicle, and approximately 1 cm was removed from the distal clavicle.
    • Report 29822, limited debridement, if: a 1 cm space was created by removing 7 mm from the distal clavicle and 3 mm from the acromion as the documentation does not meet the minimum requirements for the distal claviculectomy or the acromioplasty.
    • Report 29822 and 29826, if the 3 mm removed from the acromion is a true acromioplasty, which is achieved by converting the acromion to a type I morphology with a subacromial decompression. The 7 mm does not meet the requirements of the claviculectomy and documentation must support both services. 29826, arthroscopic subacromial decompression procedure cannot be billed for Medicare cases, because Medicare considers it as an “add-on code” which is a “packaged procedure” and therefore not separately payable.
  • Billing for “mini-open” procedures that convert to open procedure: Sometimes, a procedure may begin as arthroscopic, but becomes a “mini-open procedure if the surgeon makes an incision, and completes it as an open procedure. In this case, coding and billing must be done only for the open procedure.

These are just a few examples of the intricacies involved in shoulder surgery billing and coding. To ensure accurate claim submission and appropriate reimbursement, physicians and coders need to be knowledgeable about documentation rules to ensure proper coding of shoulder procedures. This is much easier with medical coding outsourcing to an experienced service provider.