# Arthroscopic to open~shoulder



## svms (Dec 30, 2014)

Physician started arthroscopic rotator cuff repair and due to complications had to convert to open.

I do understand that I can only code the rotator cuff repair to open (23410). 

Surgical procedure was arthroscopy left shoulder with subacromial decompression/acromioplasty (29826) and rotator cuff repair .

29826 is only able to be reported with parent codes because it is a add-on code.

The arthroscopic subacromial decompression/acromioplasty WAS successfully completed before the physician started the rotator cuff repair. 

Is it correct to change subacromial decompression/acromioplasty to open code as well? I am not sure the correct protocol in this case because the subacromial decompression was completed arthroscopically.


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## dclark7 (Jan 2, 2015)

No, it would not be appropriate to change the arthroscopic code to open. Both the open code (23130) and the arthroscopic code (29826) are bundled with 23410.


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## twizzle (Jan 2, 2015)

TeaTime said:


> Physician started arthroscopic rotator cuff repair and due to complications had to convert to open.
> 
> I do understand that I can only code the rotator cuff repair to open (23410).
> 
> ...


Keep the 29826 as arthroscopic.... yes it is bundled with the open RC repair but can be unbundled since it is a different approach. Use diagnosis code V64.43 as the secondary code on your RC repair.


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## dclark7 (Jan 2, 2015)

twizzle said:


> Keep the 29826 as arthroscopic.... yes it is bundled with the open RC repair but can be unbundled since it is a different approach. Use diagnosis code V64.43 as the secondary code on your RC repair.



According to the NCCI Policy Manual, Chapter 4 if an arthroscopic procedure is converted to an open procedure only the open procedure is reported.  Neither a surgical arthroscopy nor a diagnostic arthroscopy code should be reported with the open procedure code....


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## twizzle (Jan 7, 2015)

dclark7 said:


> According to the NCCI Policy Manual, Chapter 4 if an arthroscopic procedure is converted to an open procedure only the open procedure is reported.  Neither a surgical arthroscopy nor a diagnostic arthroscopy code should be reported with the open procedure code....



Yes, but in this case one procedure was done through the scope and one was done open so you would report both...different procedures, different approaches. You would not report arthroscopic acromioplasty and open acromioplasty since this procedure wasn't converted to open. It was already complete before the RC repair was begun once the scope was removed.


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## twizzle (Jan 7, 2015)

Rosyreh said:


> We have been instructed by an auditor at our Orthopedic Power Coding Seminar that the open procedure can be billed with a modifier -22 for Increased Procedural Services. In a cover letter, provide a detailed explanation for the increased difficulty, or highlight the work in the operative report. (Per CPT 2015: Documentation must support the substantial additional work and the reason for the additional work-ie. increased intensity,time,technical difficulty of procedure,severity of pt's.condition,physical and mental effort required)
> Examples for using modifier -22 would include the V64.43 (scope to open), or morbid obesity with a BMI of 45 or greater. (278.01 plus the appropriate
> V-code)
> She also recommends to increase the fee commensurate with the extra work effort.
> Rosemary T. Reh, CPC,COSC



I would have to disagree with your orthopedic auditor on the use of modifier 22 just because a scope procedure is converted to open. Also, morbid obesity is certainly no grounds for using a 22.
The RVU of all CPT codes is based on many factors, one of which is time. Any procedure where the "normal" time taken is increased significantly due to, for example, adhesions, excessive calcification in soft tissues, very difficult approach, excessive bleeding, those kind of things, would justify a modifier 22 as long as the provider said how much longer than normal it took, and why it took significantly longer. Morbid obesity may be a reason, but not routinely.
Converting to open may be done so as to complete the surgery to a higher standard than using a scope....no grounds for a 22 though. Chronic conditions requiring repair may be more difficult than if the problem has just occurred...RC repair is such an example. That is why there are open codes for a repair of an acute RC tear and a chronic RC tear. The chronic repair CPT has a higher RVU. A re-repair of an ACL rupture that was repaired several years previously would also probably take much longer than the initial repair, due to scarring. A modifier 22 would be justified if the provider documented the increased time and difficulty. Good dictation is essential in getting extra reimbursement though, but in no way guarantees it.


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