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CMS has posted the 4th quarter NCCI procedure-to-procedure (PTP) edits that are effective on October 1, 2022. NCCI applies to all Medicare Part B claims and may be utilized by some private payors. Two new procedure-to-procedure edits will require a change to how code 29823 is reported.

As history, readers may be aware that an NCCI guideline places restrictions on the reporting of arthroscopic shoulder debridement codes 29822 (Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures) and 29823 (Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures). 

Regarding 29822, an NCCI guideline in Chapter 4, Section E, Subsection 7 instructs that CPT code 29822 is considered inclusive to all arthroscopic shoulder procedures In the same (ipsilateral) shoulder. There are no changes to this policy effective October 1, 2022.

Regarding 29823, the same subsection explains that there are only three exceptions where code 29823 is reportable with other shoulder arthroscopy services in the same shoulder. It says:

CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder.

This guideline was effective on January 1, 2017; prior to that date no exceptions existed.

From January 1, 2014 to June 30, 2016 there were NCCI PTP edits between codes 29824/29823, 29827/29823, and 29828/29823. Because the PTP edits were removed on July 1, 2016, for the past several years a bypass modifier (e.g. distinct procedural service modifier 59) has not been needed to signify that the “different area” requirement was met for these code combinations.

Fast forward to October 2022, and NCCI is reinstating PTP edits between two of the three code pairs – 29827/29823 and 29828/29823. The rationale is “More Extensive Procedure”, which is explained in NCCI as “The ‘CPT Manual’ often describes groups of similar codes differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic sites, the less complex service is included in the more complex service and is not separately reportable.

This change means that when the CPT and NCCI criteria for 29823 are met - debridement of 3 or more anatomic structures in a different area of the same shoulder - and the code is reported with 29827 or 29828, modifier 59 or another NCCI-bypass modifier will be needed. It is not evident why no PTP edit was reinstated for 29824/29823. We will not know if NCCI is revising the narrative guideline for 29823 until closer to January 2023.

Example NCCI Format on 9/30/22                         Example NCCI Format on 10/1/22

29824, 29823-51*                                                                   29824, 29823-51*
29827, 29823-51*                                                                   29827, 29823-59
29828, 29823-51*                                                                   29828, 29823-59
 
*Under CPT rules a secondary procedure would be reported with multiple procedure modifier 51, but Medicare MACs instruct providers NOT to use it; we’ve applied it in these examples only as a distinction from distinct procedural service modifier 59. Follow payor rules.
 
Keep in mind, if other shoulder arthroscopy services are reported in the same case, and they have PTP edits with 29823, that an NCCI-bypass modifier should not be used unless the services are performed in contralateral shoulders. Examples are codes 29806 and 29807.

The 2022 NCCI guidelines and PTP edit tables can be found at:
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