Private payers are increasingly denying payment for CPT code 29826—arthroscopic subacromial decompression—when it is reported with open shoulder procedures. These coding and appeal strategies should be helpful when reporting an arthroscopic subacromial decompression in the following situations:
- independent of an open shoulder procedure
- in conjunction with an open shoulder procedure such as a mini-open rotator cuff repair
- in conjunction with other arthroscopic shoulder procedures
CPT code 29826 (arthroscopic subacromial decompression) is billed in conjunction with an open rotator cuff repair (23412) and arthroscopic distal claviculectomy (29824) and reported as 23412, 29824-51, and 29826-59. Payment is denied. The payers claim that the AAOS previously published the correct code for the arthroscopic subacromial decompression as CPT code 29822 or 29823.
Assuming documentation of both medical necessity and performance of the procedures are present, the CPT codes are correct due to changes in the coding for arthroscopic subacromial decompression.
CPT code 29826—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)—was revised in 2012. Part of the revision was a definition change; the major revision was changing the code from a stand-alone code to an add-on code. However, 29826 may only be added on to certain codes, which are specified below.
Add-on codes may not be reported independently and may only be reported if an associated index or primary procedure code is also reported. In this scenario, CPT code 29824 is the index arthroscopic procedure, enabling the reporting of CPT code 29826. CPT codes 29822 and 29823 represent débridement services.
The following rationale, which was published in the 2012 CPT Changes: An Insider’s View, can serve as official source documentation in constructing an appeal:
“To address the concerns of the AMA/Specialty Society Relative Value Service Update Committee (RUC) related to screening of codes that are performed together more than 75 percent of the time, code 29826, for reporting arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release, was converted to an add-on code. Code 29826 is billed more than 95 percent of the time with other arthroscopic repair of the shoulder codes. Therefore, it was decided that instead of relying on multiple procedure reduction rules, it would be better to convert 29826 to an add-on code. The codes that may be reported in conjunction with code 29826 are 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, and 29828. In addition, code 29826 was revised to more specifically delineate the structure involved, ‘coracoacromial ligament (ie, arch),’ and the preferred term ‘when performed’ was substituted in place of ‘with or without.’”
In this scenario, CPT code 29826 is reportable because an arthroscopic distal clavicle resection (29824) was also performed. CPT code 29824 is an appropriate index or parent code for CPT code 29826. Because a second arthroscopic shoulder procedure was performed, CPT codes 29822 or 29823 (in place of 29826 for the subacromial decompression) would not be accurate coding.
CPT code 29826 (arthroscopic subacromial decompression) is billed in conjunction with an open rotator cuff repair (23412) and reported as 23412 and 29826-59. Payment is denied. The payers claim that the AAOS previously published the correct code for the arthroscopic subacromial decompression as CPT code 29822 or 29823.
In this case, the payers are correct in recommending CPT code 29822 or 29823—so long as the arthroscopic subacromial decompression was the only arthroscopic procedure performed with the open rotator cuff repair. CPT code 23412 is not an appropriate index or parent code. The physician would report 23412 and then the appropriate limited (29822) or extensive débridement code (29823).
In addition to the previously mentioned rationale, a second source for the appeal can be found in the April 2012 CPT Assistant. This article states that CPT codes 29822 and 29823 can be reported if the arthroscopic subacromial decompression was the only procedure performed (no index or parent code). The same concept would apply to this scenario if the only procedures reported are the open rotator cuff and the arthroscopic subacromial decompression.
In the April 2012 CPT Assistant, the following question was asked: What CPT code(s) may be reported in the event arthroscopic subacromial decompression with partial acromioplasty is performed independent of any other arthroscopic shoulder procedure(s)?
The response was as follows: “Code 29822—Arthroscopy, shoulder, surgical; débridement, limited—or code 29823—Arthroscopy, shoulder, surgical; débridement, extensive—may be reported as appropriate when a subacromial decompression is done by itself. For example, if a subacromial decompression is performed alone, which usually involves débridement of soft tissue and bone removal, then code 29822 may be reported. If débridement of bone and soft tissue is performed, this code is correct and accurately describes the work done. If there is extensive work done in the removal of the soft tissue and bone, then one would report 29823.”
To construct the appeal, take the following steps:
- Ensure that the operative note clearly supports the services performed.
- Accurately submit CPT codes in descending value order.
- List the add-on code, when present, subsequent to the index or parent code. For example, CPT code 29826 must be listed on the claim form subsequent to an arthroscopic shoulder index or parent code.
- Add appropriate modifiers to subsequent stand-alone procedures.
- Appeal denials using CPT source documents or AAOS Practice Management coding tips.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.
This article was updated in November 2015. Refer to "That Was Then; This Is Now: Arthroscopic Subacromial Decompression" for current information.
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