Coding Strategy

Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

West Virginia Subscriber

Answer: Select a diagnosis based on your provider’s documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Include that diagnosis with …

… the appropriate E/M code for your physician’s service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Also report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) with 719.41 (Pain in joint; shoulder region) for the shoulder injection.

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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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