How To Use CPT Code 29916

CPT 29916 describes a specific procedure involving surgical arthroscopy of the hip joint along with labral repair. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 29916?

CPT 29916 is used to describe a surgical procedure that involves arthroscopy of the hip joint and labral repair. This code is specifically used when the provider performs both the arthroscopy and the repair of the labrum, which is the fibrocartilage that lines the rim of the acetabulum, the cup-shaped socket of the hip joint.

2. Official Description

The official description of CPT code 29916 is: ‘Arthroscopy, hip, surgical; with labral repair.’ It is important to note that this code should not be reported in conjunction with codes 29915, 29862, or 29863.

3. Procedure

1. The provider begins by preparing and anesthetizing the patient appropriately.
2. Traction is applied to the hip joint to increase the joint space for better visualization during arthroscopy.
3. The provider creates small incisions called portals over the hip joint.
4. An arthroscope, a tiny camera, is inserted through one of the portals to visualize the joint.
5. The provider then inserts surgical instruments through another portal to perform the necessary procedures.
6. The provider examines the labrum closely using the arthroscope to determine the extent of the tear.
7. If necessary, the torn labral tissue is debrided or trimmed.
8. The provider repairs the labral tear by drilling holes in the acetabular rim and suturing the labrum to the bone.
9. The capsule is repaired, and all instruments are removed from the portals.
10. The incisions are closed, and bandages are applied.

4. Qualifying circumstances

CPT 29916 is performed when there is a tear in the labrum of the hip joint. This tear may occur due to hip dislocation or structural abnormalities of the hip joint. The procedure is performed by a provider who is skilled in arthroscopy and labral repair.

5. When to use CPT code 29916

CPT code 29916 should be used when the provider performs surgical arthroscopy of the hip joint along with labral repair. It is important to note that this code should not be reported in conjunction with codes 29915, 29862, or 29863.

6. Documentation requirements

To support a claim for CPT 29916, the provider must document the following information:

• Patient’s diagnosis and indication for the procedure
• Details of the arthroscopy and labral repair performed
• Specific findings during the procedure, such as the extent of the labral tear
• Any additional procedures performed during the same session
• Start and end time of the procedure
• Any complications or unexpected events
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 29916, ensure that the procedure performed includes both arthroscopy of the hip joint and labral repair. Do not report this code in conjunction with codes 29915, 29862, or 29863. It is important to follow the specific guidelines provided by the payer regarding documentation and coding for this procedure.

8. Historical information

CPT 29916 was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes surgical arthroscopy of the hip joint with labral repair to address a labral tear caused by a structural abnormality.
2. A provider performs arthroscopy of the hip joint and repairs a torn labrum in a patient who experienced a hip dislocation.
3. A patient with persistent hip pain undergoes surgical arthroscopy of the hip joint with labral repair to address a labral tear.
4. A provider performs arthroscopy of the hip joint and repairs a torn labrum in a patient who has been experiencing hip instability.
5. A professional athlete undergoes surgical arthroscopy of the hip joint with labral repair to address a labral tear caused by repetitive hip movements.
6. A patient with a history of hip joint abnormalities undergoes arthroscopy and labral repair to alleviate pain and improve joint function.
7. A provider performs surgical arthroscopy of the hip joint with labral repair in a patient with a known labral tear.
8. A patient with chronic hip pain undergoes arthroscopy of the hip joint and labral repair to address a torn labrum.
9. A provider performs surgical arthroscopy of the hip joint with labral repair in a patient with a history of hip joint trauma.
10. A patient with hip joint instability undergoes arthroscopy and labral repair to improve joint stability and function.