How To Use CPT Code 29828

CPT 29828 is a surgical code for arthroscopic shoulder biceps tenodesis, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 29828?

CPT 29828 is a surgical code used to describe an arthroscopic procedure performed on the shoulder joint to repair an unstable biceps tendon. This procedure is typically performed to correct instability of the biceps tendon due to biceps tendonitis, inflammation of the tendon, which often accompanies other shoulder problems such as chronic instability, arthritis, and impingement syndrome.

2. 29828 CPT code description

The official description of CPT code 29828 is: “Arthroscopy, shoulder, surgical; biceps tenodesis.”

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the shoulder area.
3. The arthroscope is inserted through the incision and into the shoulder joint.
4. Saline solution is instilled to inflate the area around the shoulder joint and improve the field of view.
5. The provider inspects the muscles and tendons in the joint.
6. The damaged portion of the biceps tendon is excised, and the healthy tendon is reattached to the humerus.
7. The area is irrigated, and any bleeding is checked.
8. Any instruments are removed, and the incision is closed.

4. Qualifying circumstances

Patients eligible to receive CPT code 29828 services are those who have been diagnosed with instability of the biceps tendon due to biceps tendonitis, inflammation of the tendon, which often accompanies other shoulder problems such as chronic instability, arthritis, and impingement syndrome. The provider must determine that an arthroscopic biceps tenodesis is the most appropriate treatment option for the patient’s condition.

5. When to use CPT code 29828

It is appropriate to bill the 29828 CPT code when the provider performs an arthroscopic biceps tenodesis to repair an unstable biceps tendon in the shoulder joint. This procedure is typically performed to correct instability of the biceps tendon due to biceps tendonitis, inflammation of the tendon, which often accompanies other shoulder problems such as chronic instability, arthritis, and impingement syndrome.

6. Documentation requirements

To support a claim for CPT 29828, the following information should be documented:

• Patient’s medical history and physical examination findings
• Diagnosis of biceps tendon instability and any accompanying shoulder problems
• Rationale for selecting arthroscopic biceps tenodesis as the treatment option
• Details of the procedure, including anesthesia, incision, arthroscopic examination, tendon repair, and closure
• Postoperative care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 29828, it is important to follow the appropriate guidelines and rules. Surgical endoscopy and arthroscopy always include a diagnostic endoscopy or arthroscopy, so a diagnostic code should not be used with a surgical code. However, if the provider performs a diagnostic arthroscopy first and discovers a previously unknown condition requiring open repair, both the open repair and the diagnostic arthroscopy can be reported by appending modifier 59 to the diagnostic arthroscopy. Do not report CPT 29828 in conjunction with CPT 29805, CPT 29820, or CPT 29822. For open biceps tenodesis, use CPT 23430.

8. Historical information

CPT 29828 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates since its addition.

9. Similar codes to CPT 29828

Five similar codes to CPT 29828 and how they differentiate from CPT 29828 are:

• CPT 29805: This code is for diagnostic arthroscopy of the shoulder, which does not involve any surgical repair.
• CPT 29820: This code is for arthroscopic shoulder synovectomy, which involves the removal of inflamed synovial tissue.
• CPT 29822: This code is for arthroscopic shoulder debridement, which involves the removal of damaged tissue or bone spurs.
• CPT 23430: This code is for open biceps tenodesis, which is a more invasive procedure than arthroscopic biceps tenodesis.
• CPT 29823: This code is for extensive arthroscopic shoulder debridement, which involves a more comprehensive removal of damaged tissue or bone spurs than CPT 29822.

10. Examples

Here are 10 detailed examples of CPT code 29828 procedures:

1. A 45-year-old patient with chronic shoulder instability and biceps tendonitis undergoes arthroscopic biceps tenodesis to repair the unstable tendon.
2. A 55-year-old patient with shoulder arthritis and biceps tendon inflammation undergoes arthroscopic biceps tenodesis to alleviate pain and improve function.
3. A 35-year-old athlete with a history of shoulder impingement syndrome and biceps tendonitis undergoes arthroscopic biceps tenodesis to repair the unstable tendon and prevent further injury.
4. A 50-year-old patient with a rotator cuff tear and biceps tendonitis undergoes arthroscopic biceps tenodesis in conjunction with rotator cuff repair.
5. A 60-year-old patient with a history of shoulder dislocations and biceps tendon instability undergoes arthroscopic biceps tenodesis to stabilize the tendon and prevent future dislocations.
6. A 40-year-old patient with chronic shoulder pain and biceps tendonitis undergoes arthroscopic biceps tenodesis after conservative treatments have failed to provide relief.
7. A 30-year-old patient with a labral tear and biceps tendonitis undergoes arthroscopic biceps tenodesis in conjunction with labral repair.
8. A 65-year-old patient with shoulder osteoarthritis and biceps tendon inflammation undergoes arthroscopic biceps tenodesis to alleviate pain and improve joint function.
9. A 70-year-old patient with a history of shoulder impingement syndrome and biceps tendonitis undergoes arthroscopic biceps tenodesis after conservative treatments have failed to provide relief.
10. A 38-year-old patient with a history of shoulder instability and biceps tendonitis undergoes arthroscopic biceps tenodesis to repair the unstable tendon and prevent further injury.