Arthroscopic Gems: Hints for Accurate Coding
By Denis Rodriguez, CPC, CCS, CIRCC, CASCC
Arthroscopy refers to less invasive procedures in which an endoscope is placed within the joint for the performance of diagnostic and therapeutic procedures. As technology advances, procedures previously performed through large incisions are now performed arthroscopically. To accommodate this emerging technology, new arthroscopy, CPT® Category III codes, and HCPCS Level II codes, have been added over the past few years.
There are three general principles of arthroscopic coding:
1. If a procedure is started arthroscopically and finished open, it is coded using the open procedure code only. In such a case, assign diagnosis code V64.43 Arthroscopic surgical procedure converted to open procedure to report the arthroscopic component.
For example, a patient presents with intra-articular fracture of the distal radius. The surgeon attempts arthroscopic reduction of the fracture fragments after synovial debridement for visualization. The surgeon finds the fragments are not sufficiently mobile for arthroscopic reduction, and converts to an open reduction and internal fixation of the three distal radial fragments. CPT® coding is 25609 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments. The arthroscopic attempt at reduction and synovectomy for visualization is included in the open completion of that procedure, as indicated by V64.43, which also is reported.
2. Seven CPT® codes describe “arthroscopically aided” procedures. This means that even though part of the procedure is performed open, the arthroscopic procedure codes should be assigned. The codes are:
29850 Arthroscopically aided treatment of intercodylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)
29851 with internal or external fixation (includes arthroscopy)
29855 Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy)
29856 bicondylar, includes internal fixation, when performed (includes arthroscopy)
29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction
29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction
29892 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy)
3. Diagnostic procedures for each arthroscopic code family are included in any surgical procedures performed from that same family. The families are:
- temporomandibular (29800-29804)
- shoulder (29805-29828)
- elbow (29830-29838)
- wrist (29840-29847)
- hip (29860-29863)
- metacarpophalangeal joints (29900-29902)
Within these families, the initial code describes the diagnostic procedure and subsequent codes describe surgical procedures. The code families for the ankle (29891-29899) and the subtalar joints (29904-29907) do not contain diagnostic codes.
Note: Two codes in this section (29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament and 29893 Endoscopic plantar fasciotomy) are not technically arthroscopies (that is, they are not endoscopies within a joint), but rather are musculoskeletal endoscopies.
Although these general rules always apply, due to the unique nature of the different joints, many arthroscopy rules are specific to each joint, as shown here:
Shoulder arthroscopy codes encompass two joints in the shoulder area: the glenohumeral joint (typically called the shoulder joint) and the acromioclavicular joint. The acromioclavicular joint is the smaller of the two and there are arthroscopy codes specific to it; excision of the distal clavicle, 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) and decompression of the subacromial space, 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release, which includes partial excision of the acromion or acromioplasty.
Arthroscopic debridement of the labrum and of the undersurface of the rotator cuff (29822 Arthroscopy, shoulder, surgical; debridement, limited) may be reported separately when performed with subacromial decompression (29826), according to the May 2001 CPT® Assistant. Per the same edition, Subacromial decompression includes acromioplasty, arch decompression, excision of bursa, and coracoacromial ligament release.
Open procedures 23410, 23412, and 23420 differentiate between whether the tear is acute or chronic or how many tendons are repaired. The arthroscopic code for rotator cuff repair (29827 Arthroscopy, shoulder, surgical; with rotator cuff repair) makes no such distinctions, and can be reported whether the tear is acute or chronic; whether one, two or three tendons are repaired, or; whether one or more portals is required to repair the cuff (February 2008 CPT® Assistant).
Often the surgeon will perform a biceps tenotomy (i.e., tendon release) via arthroscopy, and then perform a tenodesis via an open procedure. In such cases, the code for open biceps tenodesis (23430 Tenodesis of long tendon of biceps) is most appropriate. Only assign the code for arthroscopic biceps when the tenodesis portion of the procedure is performed via arthroscope.
Arthroscopic capsular shrinkage (i.e., thermal capsulorrhaphy) is at times used to treat joint instability. For payers recognizing HCPCS Level II S codes, S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy is appropriate for these procedures. For payers who do not recognize S codes, CPT®29999 Unlisted procedure, arthroscopy is appropriate. This procedure generally is considered investigational and not payable by many payers.
The knee is a hinged joint and, per the American Medical Association (AMA), is composed of three compartments: medial, lateral, and patellofemoral. The compartment coding concept is important for coding arthroscopic procedures in the knee accurately.
The code for arthroscopic abrasion arthroplasty, multiple drilling and/or microfracture (29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture) may be coded per compartment so you should code microfracture of both medial and lateral femoral condyles as 29879, 29879-59 Distinct procedural service.
As the descriptor states, chondroplasty (29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)) is included in 29879 when chondroplasty is performed in the same compartment. However, a chondroplasty performed in a separate compartment may be reported separately to 29877-59 (August 2001 CPT® Assistant).
For Medicare, G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee may be reported once for a chondroplasty and/or loose body removal performed in each compartment where it is the only procedure performed. In contrast to 29879, report code 29877 only once per knee, regardless of the number of compartments in which it is performed (December 2005 CPT® Assistant).
An often overlooked code is 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure), which may be assigned for excision of fibrosis/adhesions/scar due to previous procedures or injuries. Debridement of cyclops lesions after total knee replacement(s) is a common condition for which arthroscopic lysis of adhesions is performed. Code 29884 is considered to be included in any other major arthroscopic procedure performed in the knee, regardless of whether it is performed in a separate compartment.
When synthetic plugs are used for osteochondral grafting of the knee (i.e., mosaicplasty), 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) may be assigned, even though the descriptor refers to allograft, per the December 2008 CPT® Assistant. The same, however, does not apply for the ankle. Rather than assign code 29892 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) for placement of synthetic material, report unlisted code 28899 Unlisted procedure, foot or toes.
In contrast with knee arthroscopies, compartments do not matter for wrist arthroscopies. For example, 29846 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement includes a synovectomy (29845 Arthroscopy, wrist, surgical; synovectomy, complete), regardless of whether the synovectomy was performed in a separate compartment (CPT® Assistant, December 2003).
Note that CPT® does not have an arthroscopic complete synovectomy code for the ankle. A total synovectomy is not anatomically possible because it would cause dislocation of the joint. When synovium is debrided from the medial and lateral aspects of the ankle, report a partial arthroscopic synovectomy (29895 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial), according to CPT® Assistant, December 2008.
Coding arthroscopies can be challenging; however, with a good understanding of anatomy and with applying AMA’s guidance for each joint, you can code with accuracy.
Denis Rodriguez, CPC, CCS, CIRCC, CASCC, is senior ambulatory surgery center (ASC) coder and compliance auditor for The Coding Network, LLC. He has 20 years experience in the medical field, the last eight of which have been spent exclusively in ASC coding, auditing, and education.