cpt code and description
29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY
29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION
29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB
29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL
29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE
29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED
29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE
29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY
29825 ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ
29826 ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE
29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIRaverage fee amount - $1000 - $1100
29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS
29826 - Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromialligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) average fee amount - $150 - $200
CCI Edits and Bundling CMS Guidelines
•Effective Apr. 1, 2012 the edit bundling CPT code 29822 into 29826 will be removed
•After Apr. 1, 2012, the provider may resubmit the claim if the local A/B MAC permits, or appeal previously denied claims involving the NCCI edit code pair (Opportunity to increase revenue on previously denied claims when the ASC remains updated to changes)
Co-surgery diagnosis
If there is a co-surgery, the diagnosis has to match for both OP notes.
Osteoarthritis
When coding for Osteoarthritis we will need the following to be documented within the OP note in order to code and process for billing within a timely manner. I know this is a repeat from last month, but we are starting to receive denials for the use of a more specific diagnosis code.
• Nature of Osteoarthritis (Primary, Secondary, post-traumatic)
• Laterality (Left, Right, Bilateral)
• Anatomical Location (Hip, Knee, CMC, etc.)
What to code when only an Acromioplasty is performed alone(29826) 29826 is defined as an Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).
• This code can only be reported with other scope procedures
• It is not a stand alone code
• If this is the only procedure performed, you should report 29822/29823 per CPT and AAOS
• What to do if performed with an open procedure… o CPT 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add-on code to CPT 23410 or 23412, and an unlisted code cannot be reported to reflect this work. Instead, you should report 29822 or 29823 as appropriate.
29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY
29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION
29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB
29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL
29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE
29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED
29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE
29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY
29825 ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ
29826 ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE
29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIRaverage fee amount - $1000 - $1100
29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS
29826 - Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromialligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) average fee amount - $150 - $200
CCI Edits and Bundling CMS Guidelines
•Effective Apr. 1, 2012 the edit bundling CPT code 29822 into 29826 will be removed
•After Apr. 1, 2012, the provider may resubmit the claim if the local A/B MAC permits, or appeal previously denied claims involving the NCCI edit code pair (Opportunity to increase revenue on previously denied claims when the ASC remains updated to changes)
Co-surgery diagnosis
If there is a co-surgery, the diagnosis has to match for both OP notes.
Osteoarthritis
When coding for Osteoarthritis we will need the following to be documented within the OP note in order to code and process for billing within a timely manner. I know this is a repeat from last month, but we are starting to receive denials for the use of a more specific diagnosis code.
• Nature of Osteoarthritis (Primary, Secondary, post-traumatic)
• Laterality (Left, Right, Bilateral)
• Anatomical Location (Hip, Knee, CMC, etc.)
What to code when only an Acromioplasty is performed alone(29826) 29826 is defined as an Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).
• This code can only be reported with other scope procedures
• It is not a stand alone code
• If this is the only procedure performed, you should report 29822/29823 per CPT and AAOS
• What to do if performed with an open procedure… o CPT 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add-on code to CPT 23410 or 23412, and an unlisted code cannot be reported to reflect this work. Instead, you should report 29822 or 29823 as appropriate.
Column 1 Code / Column 2 Code - 29827/29820
* CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair
* CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial
CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not modifier 59.
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
* CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair
* CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial
CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not modifier 59.
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
Rotator cuff repair and reconstruction
Use CPT code series 23410 to 23412 to report mini open rotator cuff tear repairs, with code selection determined by acute versus chronic conditions. While CPT provides a parenthetical statement under CPT 29827 (Arthroscopy, shoulder, surgical;
with rotator cuff repair) directing the CPT user to report 23412 for mini open rotator cuff repair, you still need to determine the final code selection based on the acute versus chronic condition. Recall that CPT code verbiage in 23410 to 23420 is specific to an acute versus chronic condition.
Mini open rotator cuff tear repairs typically don’t involve entry into the shoulder joint while the tear can still be visualized and repaired. When a surgeon performs an arthroscopic rotator cuff repair, report CPT 29827 regardless of whether the condition is acute versus chronic.
The operative report should specify an acute versus chronic condition. The technique (open versus arthroscopic) will need to be apparent to include a detailed description of a repair versus reconstruction of the specific tendon(s) or cuff.
Rotator Cuff Codes
CPT Code Procedure MCR
29827 Arthroscopic surgical shoulder; repair of rotator cuff $1,342.79
Background:
The Medicare beneficiary underwent a surgical procedure at the Appellant’s ASC facility on March 25, 2011. Medical documentation in the record consists of an Operative Report dated March 25, 2011 that the surgeon, Thomas B. Viehe, M.D., authored. Exh 1 at P 099. In addition to identifying the preoperative and postoperative diagnoses, the Operative Report includes a description of the procedure. The section for “Operation(s) Performed” includes the following entries:
1. Right shoulder arthroscopic rotator cuff repair.
2. Right shoulder arthroscopic subacromial decompression with partial acromioplasty.
3. Right shoulder arthroscopic distal clavicle resection.
4. Right shoulder arthroscopic glenohumeral joint debridement, extensive.
Id. The report also included a detailed description of the procedure. Id.
The ASC facility billed Medicare for CPT codes 29823 (arthroscopy, shoulder, surgical; debridement, extensive), 29824 (arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (mumford procedure)), 29826 (arthroscopy, shoulder, surgical, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed, 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) and 29999 (unlisted procedure, arthroscopy).
Wisconsin Physicians Services (WPS), the Medicare Part B contractor in the Appellant’s jurisdiction, reimbursed the facility for 29823, 29824, 29826 and 29827 but denied payment for 29999. Id. at P 097. According to the Remittance Advice, 29999 denied on the basis that “this procedure code/bill type is inconsistent with the place of service.” 1 Id.
The ASC’s basis for appeal was essentially the same at all levels: “code 29999 is used for arthroscopic biceps tenotomy, as there is no more specific code.” Exh 1 at P 093 and Exh 6 at P 022. In its redetermination notice, WPS explained:
Surgeons bill separately for physician’s services. The physician’s bill is not at issue in this case. We note, however, that review of the Health Insurance Master Record (HIMR) shows the physician billed and was paid for 29823, 29824, 29826 and 29827. We were unable to locate any record indicating the physician either billed for or was paid for CPT code 29999.3 Nothing in the Operative Report indicates that the physician performed a separate procedure, considered the biceps tenotomy to be a separately indentifiable procedure, or intended to bill Medicare for a separate procedure.
As discussed above, both the Part B contractor and the QIC allowed payment for 29823, 29824, 29826 and 29827 but denied payment for 29999 because 29999 is noncovered when provided in an ASC facility. Thus, the WPS and QIC decisions appear
to be wholly consistent with the surgeon’s report and claim information, which indicate that four separate and distinct procedures—not five—were performed and billed.
As part of its agreement with CMS, an ASC agrees to charge the beneficiary only the applicable deductible and coinsurance amounts for facility services for which the beneficiary is entitled to have payment made on his or her behalf. 42 CFR § 416.30. The Appellant billed, and was paid, for 29823, 29824, 29826 and 29827. This constitutes payment in full for services performed. Pursuant to 42 CFR § 416.30, the appellant may not charge the beneficiary for more than the applicable deductible and coinsurance for 29823, 29824, 29826 and 29827.
Conclusion:
The beneficiary underwent arthroscopic shoulder surgery at the Appellant’s ASC facility.
The Appellant billed Medicare, and was paid, for CPT codes 29823, 29824, 29826 and 29827. The Appellant also billed Medicare for unlisted procedure code 29999 because there was no specific billing code assigned to arthroscopic biceps tenotomy. Exh 6 at P 032.
CMS regulations are binding on Office of Medicare Hearings and Appeals ALJs. 42 CFR § 405.1063(a). Pursuant to 42 CFR § 416.166(b), Medicare only pays ASCs for services that appear on a list of approved services published in the Federal Register and for which separate payment is made under OPPS. CPT code 29999 is not an approved service when furnished in an ASC. 75 FR 72279-72331, November 24, 2010,
Addendum AA. Under 42 CFR § 416.166(c)(7), services that can only be reported using an unlisted surgical CPT code are excluded from coverage in an ASC. CMS has also expressly excluded CPT code 29999 from coverage when furnished in an ASC.