Diane Posted Mon 01st of April, 2019 15:32:50 PM
My doctor did arthroscopy of the left shoulder listing: arthroscopic debridement of capsule and labrum. Synovectomy superior anterior posteriorly. Excision of spur of distal clavicle and injection of joint with depo medrol. The body of the operative report states moderate degree of synovitis of the entire joint involving the anterior, superior, posterior capsule. Then states the labrum was debrided along with the anterior capsule superior and posterior capsule of very thick frond like material and what appeared to be loose bodies which were dissolved with the Mitek VAPR wand. Then he states that the distal end of the clavicle and acromion was removed. Would the codes be 29823 extensive debridement, 29821 complete synovectomy with a -59 modifier, 29824 distal claviculectomy and 20610 for joint injection be correct? Also, 29819 loose body would I be able to use that code? Thanks for advise.
SuperCoder Answered Tue 02nd of April, 2019 05:07:19 AM
Thank you for your question.
As per the above limited documentation, the appropriate codes will be CPT® code will be 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface)
As per NCCI edit, there are bundling conflicts between the CPT® codes:
29819 is included in CPT® codes 29823 and 29824
Since, the labrum was debrided along with anterior capsule superior and posterior capsule of very thick frond like material and loose bodies were dissolved with the Mitek VAPR wand; removal of loose body will not be reported separately.
29821 is included in CPT® codes 29823, 29824 and 29819
Note: The above presented documentation, do not indicate that synovectomy, complete was performed. The documentation only indicates moderate degree of synovitis of the entire joint involving the anterior, superior, posterior capsule was present. Accurate coding can be determined basis the detailed operative report.
20610 is included in CPT® codes 29823,29821, 29824 and 29819
CPT® code 20610 should not be reported when performed concurrent with another intra-articular procedure. This code may be reported separately if the post-operative pain medication injection is performed at an anatomic site other than that of the intra-articular procedure (left shoulder).
Hope that helps.
Please feel free to write if you have any question.