# Arthroscopic shoulder procedure w/open rotator cuff repair



## ruthan (Dec 14, 2018)

Help please...  I am having a issue with our Physician.  He does not think he is getting paid for everything he is doing.  I am trying to be vigilant in using the correct codes but these modifier edit's are confusing me even more now...could be overthinking.  Any advice would be so greatly appreciate....  always a learning profession....

Am I understanding this or am I way off...

Want to code this way:  23410-LT 29828-59, 29826-59 and 29823.  Not use 29820

29828, 29826 29823 (NCCI edit Presence of an anatomic site modifier on this code(s) 23410 is suppressing NCCI edit. Check documentation to determine whether both code pair(s) can be billed or an additional site modifier added)

29820 (NCCI Edit.. Code 2 of a code pair with 29828 29823 that would be allowed if an approp. NCCI modifier were present.)

DX: Acute massive RTC tear, bicep tenosynovitis, labral fraying with impingement, synovitis of the glenohumeral joint

Surgery: Arthroscopy left shoulder w/extensive debridement of the labrum, partial synovectomy, subacromial decompression with acromioplasty with bicep tenodesis and open acute roatator cuff repair


PROCEDURE:
introduced the trocar into the glenohumeral joint atraumatically and began a diagnostic arthroscopy, which demonstrated a
massive rotator cuff tear, biceps tenosynovitis with a torn labrum at the biceps insertion synovitis through the shoulder.
I performed a biceps tenotomy, which was later repaired. I debrided the stump of the biceps, utilized a shaver to circumferentially debride the labrum, and then utilized a Werewolf RF to perform a partial synovectomy of the glenohumeral joint. Once completed, I then placed the scope into the subacromial space. I started a standard anterior lateral portal and with the use of a Werewolf and shaver,
performed a subacromial decompression and bursectomy. I then identified a large spur on the acromion and performed an acromioplasty with a burr, co-planing it with the AC joint. Once completed, I then made the decision to open the rotator cuff. I then extended my
anterior lateral portal superiorly and slightly inferiorly, dissected down through the subcutaneous tissue with scissor dissection and elevated medial and lateral flaps over the deltoid fascia and then split the deltoid and the raphe between the anterior and lateral delts. I then placed a Link retractor. I identified the bicipital groove by externally rotating. I incised the transverse ligament and the pulled the biceps through the incision. I then placed a 1.8 mm Q-Fix anchor at the top of the bicipital groove. I rasped the entire groove and then whipstitched the biceps tendon with the suture from the Q-Fix. I reduced it within the bicipital groove and then tied knots over the top. I then utilized
the remaining suture to repair the transverse ligament. I then identified the massive rotator cuff tear. I debrided the insertion with a rasp and rongeur and got down to a bed of good bleeding bone and then placed three 5.5 Healicoil suture anchors along the articular margin. Each one had good bite. I then sequentially passed all twelve sutures through the rotator cuff in standard fashion. I then reduced the cuff down to the insertion and tied medial row knots. I then placed one suture from each one of the knots in an anterior lateral 5.5 mm MultiFIX-S Ultra suture anchor for my lateral row, reduced the cuff back down to the insertion very well and then repeated those same steps with the
more posterior lateral 5.5 MultiFIX-S Ultra. Overall, I was extremely happy with the reduction of the rotator cuff and the overall repair. I then thoroughly irrigated out the wound. I documented the repair with a picture and then closed the deltoid fascia with running #0 Vicryl. The subcutaneous layer was then closed with a #2-0 Vicryl and the anterior and lateral portals were closed with #3-0 nylon. I then dressed the lateral wound with Dermabond, Steri-Strips, Xeroform, 4x4s, ABDs, and Medipore tape. The patient was placed in an UltraSling, an Iceman was applied, and he was taken to PACU in stable condition.


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## Orthocoderpgu (Dec 14, 2018)

*Debridement can't be part of a restorative procedure*

Any debridement that is in preparation for a restorative procedure cannot be counted towards 29823.

Let's look at the biceps tenodesis: Performed tenotomy, debrided the stump, debrided the bone where the suture was placed. All of that debridement is part of the tenodesis procedure.

Debriding the rotator cuff tendons before a repair is included with the repair code.

The only debridement that is not part of a restorative procedure is the synovitis which is included with any procedure, and debriding the SLAP lesion (Labrum). That is not enough for 29823.

23410
29828
29823

I would include the subacromial decompression with the other debridement since it has more RVU than 29826.

You need to read CMS NCCI 2017 surgical policy manual which addresses this.

You also need to look at the insurance, since coding will change depending on the insurance (follow NCCI or not) or have they made their own coding decisions? Some allow 29823, some don't.


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## ruthan (Dec 14, 2018)

Thank you....  so then if I am understanding correctly I really only want to use 23410, 29828 and 29826? and then depending on the insurance?


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## Orthocoderpgu (Dec 14, 2018)

*Yes, it will depend on the insurance what you bill*

So far BX is not on board with 29823.

If it's not BX, I would bill 29823 instead of 29826 since it has more RVU for your doc.


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## meganszcz95@gmail.com (Dec 30, 2018)

I also have a dr who likes to do arthroscopic debridement along with open/ mini open rotator cuff repairs and/or tenodesis.  I struggle in knowing if it is kosher to be billing 29822 along with my open procedure.  Since NCCI stating that we can't bill arthro rotator cuff repair w/ limited debridement, I think it's weird that there is no edit when using 23412 and 29822.  However there is an edit between 23410 and 29822. I've read and reread the NCCi policy manual and I still have a hard time knowing what I can code together and what I can't.  If he debrides the labrum and stump arthroscopically and then repairs the rotator cuff open, I code 23412 and 29822.  If he does same arthro procedure but his open procedure is tenodesis, I only code 23440 b/c the debridement was on same area that is being repaired.  Sometimes he does the arthro debridement and then open rotator cuff repair and tenodesis.  So in this scenario, should I never be coding 29822/23 if the debridement is all on the labrum/stump and around tear?  Is this correct?  I've heard arguments that you code arthro and open b/c they are two different approaches.  But then there is the rule that if it starts arthro then converts to open, you only code open.  Any insight on this, is appreciated. 
Thanks, 
Megan CPC-A


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## Julie.Cross (Jan 28, 2020)

I am looking for somewhat of the same answer to question above. I have a surgeon who is wanting to code both the arthroscopy and mini-open rotator cuff repair and left shoulder arthroscopy with limited debridement.  Are both of these procedures coded together, 23412 and 29822


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## Orthocoderpgu (Feb 8, 2020)

The 2017 CMS NCCI Surgical Policy Manual states that limited debridement is included with all shoulder procedures. In other words, code 29822 must be billed on its own. Margie Scalley Vaught from the education department of AAOS has written a couple of shoulder surgery articles in our coding magazine in the last couple of years. In it she states that the rotator cuff is one anatomical unit (CMS incorrectly states that the entire shoulder is one anatomical unit) and due to that you cannot report both an open and arthroscopic code for RTC repair. It's one or the other, but not both. They July 2017 of Healthcare Business Monthly has a really good article. March of 2016 also has a good one on shoulder coding too.


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