Rotator Cuff Repair Coding: Catch the Arthroscopy Every Time
Posted on 09. Apr, 2009 by Editor in Hot Coding Topics
Acute or chronic? A $60 difference is at stake.
If you’re not pinpointing where the orthopedic surgeon began a shoulder surgery, you could be overlooking separately reportable pre-repair procedures.
More shoulder coding tips from Annette Grady. On MP3 or CD.
Take a swing at the following real-life shoulder situation to see how your coding skills fare.
Scenario: A 61-year-old general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem. The orthopedist’s physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear. The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.
How should you report this?
Identify Initial Procedures
First, let’s look at two portions: the labral debridement and the rotator cuff.
A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. You should begin with 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), although you’ll need to append a modifier when you add other codes.
Secondly, you should then address the open rotator cuff repair, using 23412 (Repair of ruptured musculotendinous cuff [e.g., rotator...
If you've already signed in and are still seeing this screen, click here to refresh the page.
- Free updates on CPT, ICD-9, HCPCS, Medicare, NCCI edits, and ICD-10.
- Discounts on 3rd party offers
Loading ...