Wiki How many structures debrided?

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jdibble

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Hi all,

I have a provider who wants to bill 29823 for an extensive debridement as well as 29827 for rotator cuff repair and 29828 for bicep tenodesis. Also, in the note he describes a subacromial debridement with acromion and coracoacromial ligament dissection followed by a subacromial decompression. Based on this, 29826 was also billed. I am not sure if I am seeing enough discrete structures in this part of the note below for his debridement:

29823
Synovectomy and Debridement cpt 29823
A complete synovectomy was performed with resection of inflammed tissue from the rotator interval, superior portion of the subscapularus tendon, articular surface of the supraspinatus tendon, the superior and posterior portions of the glenoid labrum and surrounding synovium. This was performed with an arthroscopic shaver and radiofrequency device. I switched and viewed from the anterior portal to complete the synovectomy and debridement in the posterior aspect of the shoulder.

He is insisting that this is a 29823. I have seen where a synovectomy would not be considered a discrete structure and would not be billed as code 29821 would represent that portion also bundles with the other codes. He has indicated to me that the subacromial decompression and debridement should be counted towards 29823 instead of 29826 as in his words, "his practice is very complex, and I do multiple procedures at once. I am not settling for billing 1 procedure only"(in regard to 29826 and not 29823). I am not sure if I do that (or if that is considered correct coding), he still has 3 or more discrete structures. Can someone review this and let me know how many structures (and what they are) were debrided aside from the other procedures billed. I think I am seeing only one - the glenoid labrum. I would also like opinions on if it is correct to forgo billing 29826 in order to have an additional structure for 29823.

Thanks for all the help! :)

Jodi
 
First of all, this is utterly run-of-the-mill surgery. As a shoulder surgeon, I threw up a little in the back of my mouth at the "my practice is very complex" comment.
You need to tell your surgeon that, if he or she wants to bill more, he needs to document more and better, and that burden is 100% on his shoulders, not yours. If the documentation doesn't match what he wants to bill, that is his fault and if he wants to addend his operative report, he can do so. (not assuming the surgeon is male, just using that pronoun for ease).

1) Partial synovectomy is included in each and every other shoulder arthroscopy code, as is limited debridement. A "complete synovectomy" is rarely performed except in the setting of rheumatoid disease or PVNS. I think your surgeon is conflating synovium with other structures in the operative note, making it harder to interpret. He should do better. If a true, "complete synovectomy" is performed, it may be separately reimbursable with 29821, but needs to be backed up with the appropriate diagnosis and documentation of medical necessity.

2) With regards to debridement, if the debridement is secondary to other work performed, it is not separately reimbursable- this includes the rotator cuff when a cuff repair is performed, and the biceps and superior labrum when a SLAP repair or biceps tenodesis is performed.

3) Subacromial decompression is not medically necessary in the setting of rotator cuff repair. This has been borne out in multiple high level studies and is reflected in the current AAOS Clinical Practice Guidelines, and will be reflected in the upcoming update in a few months as well. Because of this, most 3rd party payors will not reimburse for it. If 29826 is not submitted because it is unlikely to get paid, then the bursa and acromial spur may be considered separate areas of debridement for the purposes of coding 29823.

So basically, he either gets 29823 or 29826 depending on payor, but not both. As far as I can tell, he did a partial synovectomy and otherwise everything debrided was secondary to his rotator cuff repair. You could get away with posterior labrum or subscapularis being separate structures, but everything else is captures in the limited synovectomy which is inclusive to the other codes.
 
NRaizman said:
First of all, this is utterly run-of-the-mill surgery. As a shoulder surgeon, I threw up a little in the back of my mouth at the "my practice is very complex" comment.
You need to tell your surgeon that, if he or she wants to bill more, he needs to document more and better, and that burden is 100% on his shoulders, not yours. If the documentation doesn't match what he wants to bill, that is his fault and if he wants to addend his operative report, he can do so. (not assuming the surgeon is male, just using that pronoun for ease).

1) Partial synovectomy is included in each and every other shoulder arthroscopy code, as is limited debridement. A "complete synovectomy" is rarely performed except in the setting of rheumatoid disease or PVNS. I think your surgeon is conflating synovium with other structures in the operative note, making it harder to interpret. He should do better. If a true, "complete synovectomy" is performed, it may be separately reimbursable with 29821, but needs to be backed up with the appropriate diagnosis and documentation of medical necessity.

2) With regards to debridement, if the debridement is secondary to other work performed, it is not separately reimbursable- this includes the rotator cuff when a cuff repair is performed, and the biceps and superior labrum when a SLAP repair or biceps tenodesis is performed.

3) Subacromial decompression is not medically necessary in the setting of rotator cuff repair. This has been borne out in multiple high level studies and is reflected in the current AAOS Clinical Practice Guidelines, and will be reflected in the upcoming update in a few months as well. Because of this, most 3rd party payors will not reimburse for it. If 29826 is not submitted because it is unlikely to get paid, then the bursa and acromial spur may be considered separate areas of debridement for the purposes of coding 29823.

So basically, he either gets 29823 or 29826 depending on payor, but not both. As far as I can tell, he did a partial synovectomy and otherwise everything debrided was secondary to his rotator cuff repair. You could get away with posterior labrum or subscapularis being separate structures, but everything else is captures in the limited synovectomy which is inclusive to the other codes.
Click to expand...
Thank you Dr. Raizman. As always, you are very helpful. Now I just need to find a way to explain this to this doctor, as you can tell, he thinks he has already documented all he needs!
 
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