Orthopedic Coding Alert
Bundle Biopsy Into Arthrotomy
Question: Encounter notes indicate that the orthopedic surgeon performed a right shoulder arthrotomy with biopsy. What code(s) represent this surgery? Can I report the biopsy separately from the arthrotomy? 星空入口Forum Subscriber Answer: No, you cannot report the biopsy separately. CPT庐 code descriptors for this procedure all read 鈥渋ncluding biopsy鈥� or 鈥渨ith or without biopsy,鈥� so there鈥檚 no opportunity to code biopsy separately. You will, however, need some more information on the arthrotomy specifics. Do this: Go back and check the notes, and try to find out which joint the surgeon treated: glenohumeral, acromioclavicular, or sternoclavicular. Then, choose from one of the following codes for the arthrotomy: Also, append modifier RT (Right side) to the arthrotomy code to indicate laterality. 
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