There are significant changes for 2021 in how to use CPT codes to bill for many Orthopedic procedures. This email will focus on changes to arthroscopic loose body removals.
In case you haven’t already incorporated this information into your billing, here is the relevant information:
Arthroscopic Loose Body Removals
The AMA is now providing guidance and clarification when it comes to being able to bill and report separately for arthroscopic loose body removals. These updated guidelines apply to all the different joints, shoulders, elbows, hips, knees, ankle and subtalar joints.
In the 2021 CPT Manual, the subsection guidelines will now state “Arthroscopic removal of loose body(ies) or foreign body(ies) (i.e. 29819, 29834, 29861, 29874, 29894, 29904) may be reported only when the loose body(ies) or foreign body(ies) is equal to or larger than the diameter of the arthroscopic cannula(s) used for the specific procedure – and can only be removed through a cannula larger than that used for the specific procedure or through a separate incision or through a portal that has been enlarged to allow removal of the loose or foreign body(ies).
You will want to make sure that you add this specific information to your operative note if loose bodies/foreign bodies are removed during your arthroscopic surgical procedures.
For documentation, you might consider:
- Using appropriately specific diagnosis language
- Appropriately listing the order of the operative procedures to help your coders
- Documenting separate portals (if used) to support the use of additional codes
- Appropriate description of surgical thought process to articulate why additional procedures were performed
For the latest clarification on Limited and Extensive Shoulder Debridement, please click here