Coding Strategy

10-2:00 in the op note signals SLAP lesion repair.

Even experts can land on the wrong ICD-9 code for SLAP lesion repair, but visualizing the injury region as a clock will help you distinguish one type of SLAP (superior labral anterior posterior) tear from another.

Research Patient History for Accurate Diagnosis

Having a solid understanding of anatomy and knowing the severity of the patient’s situation give your coding a firm foundation.

Define it: The labrum is the rim of cartilage that deepens the shoulder socket (glenoid) and increases joint stability. The superior portion of the labrum can be torn when the shoulder dislocates forwardly (anteriorly). This results in a SLAP lesion — a tear of the superior labrum, anterior to posterior, says William J. Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C.

Patients can acquire a SLAP lesion after falling down, or following repeated overhead actions such as throwing a football. Symptoms include pain, swelling, and an occasional “clicking” sound when moving the arm in a throwing position.

Diagnose it: The diagnosis you submit depends on the physician’s clinical diagnosis and whether the injury is acute or chronic. Two of the most common diagnoses you’ll encounter are:

• For acute injuries, use 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) . “Code 840.7 requires an injury date, so be sure the physician notes it in the patient record,” Mallon says.

• Code 718.01 (Articular cartilage disorder; shoulder region) applies to chronic or degenerative injuries.

Avoid this: Coders sometimes report 718.81 (Other joint derangement, not elsewhere classified; shoulder region) for SLAP lesions, but that’s not your best choice because the labrum is not articular cartilage. 718.01 is more accurate for chronic or degenerative SLAP lesions for instability.

Verify Injury’s Severity to Determine Level

Four types of SLAP lesions are clinically important for your coding purposes. SLAP lesions range from degenerative fraying of the labrum to extension of the SLAP lesion beneath the middle glenohumeral ligament. Each type describes tears of the labrum or work done on certain sections of the glenohumeral (GH) joint capsule. Your code choice will hinge on the type of SLAP lesion and whether your surgeon performs debridement or repair. Possible codes for reporting based on the surgical procedure include:

• Type I — 29822 (Arthroscopy, shoulder, surgical; debridement, limited)

• Type II — 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion) for arthroscopic repair of a SLAP lesion. “Note that this code is specific for SLAP repair,” says Cristina Bentin, CCS-P, CPC-H, CMA, founder of Coding Compliance Management in Baton Rouge, La. “Unless verified that this is a SLAP, 29807 is not reported for labrum tears that are not specifically SLAP tears.”

• Type III — 29822 or 29807, depending on the extent of injury and your physician’s approach

• Type IV — Coding for a Type IV SLAP lesion varies according to the procedure performed. Documentation indicating a SLAP repair might warrant 29807, Bentin says. However, other procedures performed in combination with the SLAP repair might justify 29807 in addition to other codes. “With Type IV SLAP lesions, most surgeons proceed to arthroscopic biceps tenotomy or biceps tenodesis,” Mallon says. Report biceps tenodesis with 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis). CPT does not include a code for arthroscopic tenotomy, so you would report 29999 (Unlisted procedure, arthroscopy) unless the surgeon completes other work in the area that justifies additional or alternate codes. For example, Mallon says to code the procedure with 29823 (… debridement, extensive) for debridement of both the anterior and posterior compartments of the GH joint.

Watch: Types II and IV SLAP lesions undergo surgical repair most often; your physician can treat the other types of lesions with debridement rather than repair. The surgeon’s documentation must support the type of SLAP lesion being repaired and will determine the code you assign. Look for information about the type of SLAP lesion treated and whether the surgeon debrided both the anterior and posterior compartments of the GH joint.

Let the Clock Narrow Your Choices

Orthopedic surgeons often use clock face terminology when describing the location of a labral tear or ligamentous detachment or laxity, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. They might make statements in their operative reports such as “the labrum was seen to be detached from 3 o’clock to 6 o’clock.” But what does that kind of documentation mean?

Imagine a clock face and picture where each number is. Now imagine that clock face as the shoulder joint. Stout says that labral tears that occur in the area from 10 o’clock to 2 o’clock are referred to as SLAP lesions.

“Report 29807 when your surgeon repairs a lesion between the 10 o’clock and 2 o’clock positions,” Stout says. “If the surgeon does not use the term ‘SLAP lesion’ but describes repair of a superior labral tear between 10 o’clock and 2 o’clock, you can use 29807.”

Double check: You might want to ask your surgeon for confirmation that he did complete a SLAP procedure before reporting 29807 in the latter scenario.

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Pain management, anesthesia, orthopedic, physiatry & neurology coders get ready for a facet joint codes shift that preps for ICD-10.

The 2010 version of CPT attempts to organize the facet joint injection codes by deleting 64470-64476 and debuting 64490- 64495 in their place, as follows:

• 64490 — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

• 64491 — … second level

• 64492 — … third and any additional level(s)

• 64493 — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

• 64494 — … second level

• 64495 — … third and any additional level(s).

“Pain management coders are going to have to be on the ball to read these, to make sure that they don’t code these inappropriately,” says Leslie Johnson, CPC, quality control auditor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net. “I like the fact that they include the terminology of ‘zygapophyseal joint’ and further expound with ‘or nerves innervating that joint,’” she says.

This means that there may be other eponyms or names for nerve blocks that may fall into this brand new CPT code description, Johnson says. “Physicians are going to have to be more specific if they are going to pinpoint the correct code(s) for what they’re doing,” she says. “If it’s stated as a ‘dorsal rami injection,’ will it be a third occipital nerve block (64450 if by scalp or 64999, unlisted) or will it be 64490?” Johnson asks.

Communication and partnership between the coder and the physician is going to be more crucial than ever before, Johnson says. “Watch for increasing levels of specificity to surface as we near the deadline date for the implementation of ICD-10.”

Don’t miss Leslie Johnson, Marvel Hammer, Joanne Mehmert & other experts at the Pain Management Coding & Reimbursement Conference in Orlando. December 6-8.

Don’t want to travel? Get a specialty-specific audio coding update for your entire practice for just one low price!

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Choose this ICD-9 code if you see ‘jumper’s knee’ in the orthopedic surgeon’s note.

Here’s a handy introduction to common ICD-9 codes related to the knee, along with examples of CPT codes for procedures physicians perform to treat knee diagnoses.

Chondromalacia Patella

Chondromalacia patella (717.7) is also known as “patellofemoral syndrome” or “runner’s knee.” This condition results when the cartilage under the patient’s patella becomes damaged and causes pain particularly when the patient climbs stairs or bends his knee.

This is a common condition among runners or other athletes who jump, squat or climb. But chondromalacia patella can also be associated with arthritis, so the condition affects patients in all age groups.

When NSAIDs, physical therapy and rest do not alleviate the patient’s symptoms, the surgeon may opt to perform arthroscopic lateral release (29873) or chondroplasty (27425) to repair the damage.

Iliotibial Band Syndrome

When a patient’s distal iliotibial band causes an excessive amount of friction as it slides over the lateral femoral epicondyle during knee extension, the patient may suffer from iliotibial band syndrome (728.89). This condition, which usually affects athletes such as runners and cyclists, is characterized by pain localized over the lateral femoral epicondyle that occurs during vigorous knee movement.

When conservative treatments are ineffective, the surgeon may perform surgery, such as an iliotibial band release (27305).

Ligament Injuries

The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) connect the femur to the tibia. These ligaments are inside the knee joint. The ACL controls rotation and forward movement of the femur, and the PCL controls backward movement of the tibia.

The medial collateral ligament (MCL) provides stability to the inside of the knee, and the lateral collateral ligament (LCL) stabilizes the knee’s outer side.

For an ACL injury, the surgeon will usually perform an arthroscopic ACL repair (29888) or thermal shrinkage (29999). You will probably rely on 29889 for an arthroscopic PCL repair.

If the physician treats a collateral ligament injury, the surgeon may repair or reconstruct the ligament as an open procedure (27405, 27427, 27429).

Head of right tibia, seen from above

Meniscal Tears

Many coders are usually very familiar with meniscal tears because this is a common injury involving torn cartilage at the knee. You will see documentation that the patient has torn one of two knee menisci: the medial meniscus (836.0), located on the inside of the knee, and/or the lateral meniscus (836.1), located on the outside of the knee. These menisci serve as shock absorbers for the knee, but are easily torn as a result of wear-and-tear by athletes. Patients also may tear the menisci as a result of trauma, such as squatting or twisting the knee. Meniscus tears can also be degenerative, especially in the older population (717.0, 717.49).

Patients usually present with pain, swelling and occasionally locking of the knee. The surgeon will confirm the diagnosis using an MRI and will usually prescribe rest, anti-inflammatories or physical therapy.

If these conservative therapies fail, the surgeon will usually perform an arthroscopic meniscectomy or meniscus repair (29880, 29883) or a meniscal transplant (29868).

Osteochondritis Dissecans

Osteochondritis dissecans (732.7) occurs when the femoral condyles and the adjacent cartilage lose blood flow. This causes part of the bone to die and produce a lesion or multiple lesions that cause pain and swelling.

If the lesion does not heal or becomes detached, the surgeon may perform arthroscopic surgery (29874, 29885, 29887) or autologous chondrocyte implantation (27412) to heal the injury.

Tendonitis/Bursitis

Knee inflammation is often caused by tendonitis or bursitis (726.60, 726.69) of the knee.

If the tendons in the knee become inflamed, the patient may be suffering from tendonitis, most commonly in the patellar tendon. Your physicians may also refer to patellar tendonitis (726.64) as “jumper’s knee” because it can be caused by excessive squatting and jumping.

If the knee’s bursa becomes inflamed, the patient may have knee bursitis, usually in the bursa that lies on the patella. This condition is called “prepatellar bursitis” (726.65).

Physicians usually prescribe rest and avoidance of the activity that led to the bursitis or tendonitis, along with NSAIDs and possibly injections for tendonitis (such as 20550) or arthrocentesis for bursitis (such as 20610). Physicians don’t often perform surgery to treat these conditions.

ASC Coders: Toughen up your knee and shoulder coding with Cristina Bentin in Orlando, December 6-8.

Orthopedic Coders: Prepare for your COSC™ specialty coding credential exam. Coming to a city near you.

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