What’s New for Shoulder Surgical Procedure Coding

Get to Know Modifier 59, when to use Code 29826, and All about Debridement

Billers and coders are sailing into 2020 with a host of new updates for shoulder surgical procedures that they need to be familiar with.

This complex, fast-changing coding environment demands attention to detail, says orthopedics expert Margie Scalley Vaught. Vaught, who has more than 30 years of experience in healthcare and has held positions ranging from nurse’s aide to medical transcriptionist to office manager, will host a detail-packed hour-long live webinar on June 25 to update billers, coders, and practice managers on what is new for shoulder surgical procedure coding for 2020 and what to expect in 2021.

There are a few key areas that coders should understand when it comes to surgical procedures for the shoulder, said Scalley.

Modifier 59: The CPT Manual defines modifier 59 as a distinct procedural service used to indicate that a procedure or service was “distinct and independent” from other non-E/M serviced performed on the same day. Use it to identify procedures or services which aren’t normally reported together and when doing so is appropriate under the circumstances.

What’s key, says the Centers for Medicaid & Medicare Services, is that modifier 59 should not be used to bypass a procedure-to-procedure edit unless the right criteria are met—and that means anyone using it will need the right documentation.

“Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ,” notes CMS.

Other appropriate uses include procedures performed in different encounters on the same day, when the narrative description of the two codes is different, for two services described by timed codes done during the same encounter and performed sequentially, and for a diagnostic procedure subsequent to a complete therapeutic procedure that is “not a common, expected, or necessary follow-up to the therapeutic procedure.”

Code 29826 (Arthroscopy, shoulder surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament release, when performed): 29826 is part of a family of arthroscopy shoulder surgery codes. The acromion is “the outer end of the scapula, extending over the shoulder joint and forming the highest point of the shoulder, to which the collarbone is attached.” In a subacromial impingement, the rotator cuff tendon is pinched between the humeral head and the acromion.

CPT has made 29826 an add-on code, which means that to report it, you have to use a designated parent code—it can’t be reported as a stand-alone code. Again, you will need the right documentation to use this code. What if the only procedure carried out is 29826? If that is the case, CPT recommends you instead use 29822, Arthroscopy, shoulder, surgical; debridement, limited, or 29823, Arthroscopy, shoulder, surgical; debridement, extensive.

Also, notes SuperCoder, “Coders have been reporting code 29999 (Unlisted procedure, Arthroscopy) when only an arthroscopic subacromial decompression of the shoulder was performed.”

Extensive vs. limited debridement: Knowing the difference between these two codes is key, says Vaught, and there’s plenty of confusion among professionals about where to draw the line between the two. Here’s a basic breakdown:

29822: For minor debridement of soft tissue, including labral debridement, cuff debridement, and so on. A limited debridement can also include labral debridement, synovectomy, removal of a humeral or glenoid osteophyte, articular shaving and/or chondroplasty, and diagnostic arthroscopy.

29823: Either for debridement of multiple soft tissue structures (labrum, subscapularis, supraspinatus) and/or a chondroplasty of the humeral head or glenoid. Extensive debridement can also the same procedures listed under 29822 plus biceps, tendon, and rotator cuff debridement, and abrasion arthroplasty. NOTE: Because 29823 pays more than 29822, coders may be tempted to cite it, but using it should only be done if the surgeon performs all of those procedures. Again, proper documentation will be your friend.

The importance of documentation: As you’ve seen, proper documentation is not optional—it’s mandatory to ensure proper coding and to keep you out of payers’ crosshairs—and any problems from Centers for Medicaid & Medicare Services.

Improper documentation can cost your practice, but it’s not always easy to get physicians on board, notes Becker’s Hospital Review. NeuMD offers five suggestions, noting that better documentation helps not only coding efforts but also decreases the chances of physician queries and provides better continuity of care:

  1. Define professional standards: Create guidelines for notetaking that mesh with industry standards, with prioritization for clarity, brevity, and the needs of other readers.
  2. Expand education: Don’t assume that staff, both new and old, understand documentation standards, and keep in mind that documentation skills can always be improved.
  3. Create peer-to-peer support systems: Nominate a physician leader to take charge of documentation improvements—that puts your expertise in-house and reduces the need to lean on electronic health record vendors and third-party trainers.
  4. Review information: Taking just a few minutes to review notes can catch small errors and improve the overall accuracy of electronic health records. Expect some pushback from physicians who will cite concerns of lost productivity by noting that soon the review will become an everyday routine.
  5. Allow patients better access to electronic health records: Don’t discount the ability of patients to catch errors in electronic health records. Finding mistakes, even small ones, can help optimize treatment and improve documentation.

Overall, better coding will reduce billing errors and reduce the number of problems that providers face with payers and carriers.

“When a biller or coder makes a mistake, it can delay the claims process, cause a loss of revenue and/or affect a patient’s care,” notes MTI College. To ease any problems, coders should stay on top of coding changes, be diligent and check their work, communicate any concerns or questions, and follow through to make sure that information and documentation are submitted properly and that claims are paid correctly and on time.

Being proactive is key when you are medical billing, says Vaught, the host of the ProfEd | onDemand webinar. Avoid denied and rejected claims, and smooth your office workings, by understanding key concepts and knowing when to apply them.

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