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A diagnostic arthroscopy of the shoulder, identified by CPT® Code 29805, is a minimally invasive surgical procedure that allows for the examination of the shoulder joint. This procedure can be performed with or without a synovial biopsy, which involves taking a small sample of the joint lining for further analysis. During the procedure, the patient is typically positioned either in a lateral decubitus position, where they lie on their side with the arm suspended, or in a beach chair position, which allows for better access to the shoulder. To facilitate the examination, skin traction is applied to the arm, ensuring that the shoulder joint is adequately exposed.
Once the appropriate position is established, incisions are made at the anterior and posterior portals of the shoulder joint. A sterile saline solution is then introduced into the joint space to expand it, providing a clearer view of the internal structures. Arthroscopic instruments are inserted through these incisions, enabling the surgeon to conduct a thorough diagnostic examination of the shoulder joint. The procedure involves assessing various components, including the humeral head and glenoid fossa for any osteochondral defects, as well as the anterior and posterior labrum for signs of fraying or instability.
Additionally, the anterior joint capsule, subscapularis, and glenohumeral ligaments are evaluated for potential tears, adhesions, or fraying. The biceps tendon is also inspected for any signs of tears, inflammation, or degenerative changes. The rotator cuff, particularly the supraspinatus and infraspinatus tendons, is examined, along with the subacromial space. Finally, the posterior aspect of the glenohumeral joint, including the axillary pouch and posterior recess, is assessed. Upon completion of the diagnostic evaluation, the instruments are carefully removed, excess fluid is drained from the joint, the incisions are closed, and a sterile dressing is applied to protect the surgical site.
© Copyright 2025 Coding Ahead. All rights reserved.
The diagnostic arthroscopy of the shoulder (CPT® Code 29805) is indicated for various conditions and symptoms that may affect the shoulder joint. The following are explicitly provided indications for this procedure:
The procedure for diagnostic arthroscopy of the shoulder involves several key steps that are performed to ensure a thorough examination of the joint. The following procedural steps are outlined:
Following the diagnostic arthroscopy of the shoulder, patients can expect specific post-procedure care and considerations. It is important to monitor the surgical site for any signs of infection or complications. Patients may experience some discomfort and swelling, which can be managed with prescribed pain relief medications. Rehabilitation exercises may be recommended to restore range of motion and strength in the shoulder. The healthcare provider will provide specific instructions regarding activity restrictions and follow-up appointments to assess recovery progress. Overall, the expected recovery time may vary based on individual circumstances and the extent of any findings during the procedure.
| Short Descr | SHO ARTHRS DX +- SYNOVIAL BX | Medium Descr | DIAGNOSTIC ARTHROSCOPY SHOULDER +- SYNOVIAL BX | Long Descr | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 149 - Arthroscopy |
| QX | Crna service: with medical direction by a physician | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2021-01-01 | Changed | Short and medium descriptions changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2002-01-01 | Added | First appearance in code book in 2002. |
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