CPT Code and Descripiton
▪ 29824 – Arthroscopic claviculectomy including distal articular surface ▪ 29827 – Arthroscopic rotator cuff repair ▪ 29828 – Biceps tenodesis
Coding and Billing Guidelines.
Description of Special Study: The CERT review contractor conducted a special study of claims with lines for arthroscopic rotator cuff repair procedures billed with Healthcare Common Procedure Coding System (HCPCS) code 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) submitted from January through March 2016.
Most improper payments for HCPCS code 29827 in this special study were due to insufficient documentation errors. Insufficient documentation means something was missing from the medical records. For example, claims with insufficient documentation lacked one or more of:
• Supporting documentation for the medical necessity of the procedure
• Procedure note
• Physician’s signature, or signature attestation, on a procedure note or diagnostic report
An orthopedic surgeon billed for HCPCS code 29827 and submitted the following:
• Signed operative report
• Signed pre-operative History and Physical for medical clearance prior to surgery
WHAT YOU SHOULD KNOW
Most improper payments for HCPCS code 29827 in this special study were due to insufficient documentation errors. Insufficient documentation means something was missing from the medical records.
An orthopedic surgeon billed for HCPCS code 29827 and submitted the following:
• Signed operative report which documented left rotator cuff repair, repair of Superior Labral tear from
Anterior to Posterior (SLAP) lesion, and biceps tenotomy
• Unsigned orthopedic surgeon’s note which documented a fall injury with pain in the rotator cuff distribution and weakness in the arm, with tenderness and pain over the distal aspect of the biceps
• Unsigned orthopedic surgeon’s note which documented left shoulder rotator cuff tear via Magnetic Resonance Imaging (MRI) with persistent weakness and failed conservative care measures
• Two unsigned orthopedic surgeon’s post-operative follow-up visit notes
The use of 29822 (limited debridement) is always included in the primary procedure code for rotator cuff repair (29827) and should not be approved as a separate charge. Similarly, 29823 (extensive debridement) is generally included in 29827 when the debridement is in the same area as the rotator cuff repair, such as when done for calcific tendonitis. Acromioplasty (29826) can be billed in addition to 29827
cpt code – 29827 Discription – Arthroscopy, shoulder, surgical; with rotator cuff repair
Billing policy under ASC setup
The Appellant, an ambulatory surgical center (ASC), billed Medicare for ASC facility payments for Current Procedural Terminology (CPT) codes 29823 (arthroscopy, shoulder, surgical; debridement, extensive), 29824 (shoulder arthroscopy/surgery – mumford procedure), 29826, (shoulder arthroscopy/surgery), 29827 (arthroscopy, rotator cuff) and 29999 (unlisted procedure, arthroscopy). The Medicare contractor reimbursed the ASC for 29823, 29824, 29826 and 29827 but denied payment for 29999 because codes identifying unlisted procedures are noncovered when provided in an ASC facility. The ASC appealed the decision on the basis that there is no specific CPT code for arthroscopic biceps tenotomy. The denial was upheld at the first two levels of appeal.
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.
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 identifiable 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.
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. Ex 6 at P 032.
