# opinions please - I have a physician



## Anna Weaver (Jul 22, 2009)

I have a physician who would like to code 29805, 23412, 23130.

I am having a time with this one. Would like opinions please.

The patient was put in the supine position under general anesthesia and then he was turned over in a lateral decubitus. After preparation and drapement on the left arm, while it was hanging in traction with a posterior approach, the arthroscope was inserted and inflow and outflow was established. 

The synovial membrane was normal. He has some glenohumeral degenerative joint disease. In some areas even you could see the subchondral bone. Glenoid labrum was intact circumferentially. There was no evidence of biceps degeneration or tear that I could see. At this time, the rotator cuff was inspected and the retracted chronic tear was identified. This was large enough to warrant minimally open repair.

At this time the scope was removed and the patient was re-prepped and re-draped using a beach chair position. Following that through an anterior approach an incisiion was made and was taken down through the subcutaneous tissue using a muscle splitting approach between the medial and lateral head of the deltoid. The approach was made towards the subacromial space. The coracoacromial ligament was excised and the anterior edge of the acromion was exposed. At this time decompression acromioplasty and resection of the anterior edge of the acromioin was exposed. At this time decompression acriomioplasty and resection of the osteophytes underneath the AC joint was done. A bursectomy was carried out. Full thickness rotator cuff tear with almost about a centimeter and a half retraction was noted. The edges were freshened up. The foot plate of the rotator cuff on the greater tuberosity was prepared. At this time using absorbable screw anchor sutures were used for a second row repair of the rotator cuff. AT the end fixation was excellent. The shoulder was taken to a full range of motion with no evidence of impingement and the repair was excellent. Irrigation and primary closure and dressing was applied. An arm sling was applied. The patient tolerated the procedure well and left the operating room in a stable condition. There were no complications through this procedure.

Now, do you think he should be able to charge all 3 codes? I have fought this before and lost, I code this surgery (with the understanding that it may or may not pay) 23412, 23130-59. Now he wants to add in the 29805 diagnostic arthroscopy. I am on the fence with this one. I see where he thinks it should, but everything I have read indicates that if the surgery turns into an open procedure, that's what you code. 
Any opinions out there? Please? All are welcome! I need some discussion on this so I know where I'm going! whether I'm on the right track, or not. Thanks!


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## martnel (Jul 22, 2009)

Diagnostic arthroscopy is always included in a surgical arthroscopy (CPT book), and as far as I have seen, you can only code diagnostic if it is the only procedure in that area.

From CodeX Software:

CPT Code: 23412

Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

Intraoperative services included in the global service package, when indicated:

	1.	local infiltration of medication(s), anesthetic or contrast agent before, during, or at the conclusion of the operation (eg, 11900, 11901, 15860, 20500, 20501, 76080, 90765-90779)
	2.	suture or staple removal by operating surgeon or designee (eg, 15850, 15851)
	3.	surgical approach, with necessary identification, isolation, and protection of anatomical structures, including hemostasis and minor skin scar revision
	4.	obtaining wound specimen(s) for culture
	5.	wound irrigation
	6.	intraoperative photo(s) and/or video recording, excluding ionizing radiation
	7.	intraoperative supervision and positioning of imaging and/or monitoring equipment by operating surgeon or assistant(s)
	8.	insertion, placement, and removal of surgical drain(s), re-infusion device(s), irrigation tube(s), or catheter(s)
	9.	closure of wound and repair of tissues divided for initial surgical exposure, partial or complete (eg, 12001-12057)
	10.	application of initial dressing, orthosis, continuous passive motion, splint or cast, including traction, except where specifically excluded from global package 
	11.	preparation and insertion of synthetic bone substitutes, osteoconductive and osteoinductive agents (eg, hydroxyapatite, calcium phosphates, coral, methylmethacrylate, demineralized bone matrix, bone morphogenetic proteins),  except where specifically excluded 
	12.	arthrotomy, shoulder (eg, 23040)
	13.	coracoacromial ligament release (eg, 23415)
	14.	deltoid reattachment to acromion
	15.	excision of bursa and/or calcium deposits (eg, 23000)
	16.	excision of acromioclavicular joint osteophyte(s)
	17.	mobilization of local tissue for rotator cuff repair
	18.	manipulation, shoulder (eg, 23700)
	19.	arthroscopy, shoulder, diagnostic (eg, 29805)

Intraoperative services not included in the global service package, when indicated

	1.	supplies and medication (eg, codes 99070, HCPCS Level II codes)
	2.	complex wound closure (eg, application of wound vacuum device to open wound, (eg, 97605-97606)) or closure requiring local or distant flap coverage and/or skin graft, when appropriate (eg, 13100-13160, 14000-14350, 15000-15400, 15570-15776)
	3.	insertion, removal, or exchange of nonbiodegradable drug delivery implants (eg, 11981-11983)
	4.	harvesting and insertion of tendon/fascial graft(s) from distant site
            (separate incision) (eg, 20920, 20922, 20924)
	5.	excision of distal clavicle (eg, 23120, 29824)
	6.	partial acromioplasty (eg, 23130, 29826)


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## Penquis (Jul 22, 2009)

While it has been awhile since I coded orthopaedica, I ran those codes throught the encoder and 29805 bundles with both of the other codes.  Also 23412 bundles 23130  and  23130 bundles 23412. Have you gotten paid when you used 23412 and 23130 with modifier 59 on one of them?  If not, it would be my opinion that the provider needs to determine what was the major procedure and code for that.  Just a thought.  Good luck.


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## Anna Weaver (Jul 22, 2009)

*opinions*

Thanks! I appreciate your replies, it looks like I was on the right page after all. We were denied one claim with 23130-59 as inclusive. I anticipated that and I tried to explain that to the Dr. I thought they were inclusive, but the article he has from AAOS says it can be unbundled with a 59. Actually this was a compromise. He was billing 23420 for this surgery, but I told him we couldn't do that one. I tried to get the 23412 by itself, but he didn't agree. Now he's adding in the diagnostic, So, I will have to fight this one out also. Thanks guys for all your help! I appreciate it.


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## mbort (Jul 23, 2009)

make sure the documentation supports the bony work that is involved for the 23130.  If he did it strictly for visualization, then the 59 is not justified.


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