# Shoulder surgery opinions please



## Anna Weaver (Jul 9, 2010)

I would like someone else to review this report for me please and see what you get for codes. I must confess to having difficulty with this physician and I'm not sure if I'm being "nitpicky" as he states or if I clearly don't understand what he's trying to say. I see where he exposed and excised the coracoacromial ligament and bursa, I see where the rotator cuff was identified, I see where the biceps tendon was repaired, I do not see where he mentions correcting the rotator cuff. He told me I was nitpicking and that it was very clear for any other surgeon to see. Maybe it's just my difficulties with this physician that makes it unclear to me? Would like your honest opinions please. If I'm wrong, I want to get myself back on track. 

Preop Dx: rotator cuff tear, right shoulder, impingement syndrome with type 3 acromion and degenerative OA of acromioclavicular joint, right shoulder., 90% partial tear of the long head of the biceps tendon at the right shoulder.

Procedures:
Decompression acromioplasty resection of the coracoacromial ligament and subacromial bursectomy and removal of the osteophytes inferior to the acromioclavicular joint, right shoulder
Primary repair rotator cuff tendon utilizing arthrex corkscrew and swivelock repair of the rotator cuff, right shoulder
biceps tenodesis, right side.

Description of procedure: The patient was put in the supine position under general anesthesia with endotracheal intubation and then he was positioned in a beach chair position after prep and drape of the right shoulder and arm, using a 1-inch incision extending from the acromion over towards the coracoid, was made. The deltoid was opened along its fibers between the medial and lateral head. Type 3 acromion was exposed subperiosteally and this was excised, as well as the coracoacromial ligament and subacromial bursa.

After having this part of the surgery done, the rotator cuff was identified. It was torn not only longitudinally from the infraspinatus, but also it was totally detached from its footplate on the greater tuberosity. At this time, the joint was exposed and seen very easily. Irrigation was performed. The biceps was found to be only attached to the glenoid with only less than 10% of its width. The rest of it was shredded and partially torn right over the edge of the tuberosity and the tunnel. At this time, the biceps was detached from its glenoid attachment and, using a keyhole tenodesis, a tunnel was made inside the humerus and the tendon was rolled over itself and stuffed into the keyhole and locked in place with even elbow flexion and extension excellent fixation was achieved.

Irrigation was performed. The edges of the tendon were freshened up. The footplate of the humerus was cleaned out and prepared for the acceptance of the anchor sutures. The longitudinal part of the tear was repaired with non-absorbable ethibond and then placing three anchor sutures strategically, fiber wire sutures were passed through the tendon and the tendon was reduced over the tuberosity and was tightened. Using swivelock technique, a second row repair was perfomred on the side of the humerus. At the end repair was fantastic. The shoulder was taken to full range of motion with no evidence of impingement and no evidence of any disturbance at the area of the repair. Copious irrigation with bacitracin and irrigation solution was performed and, at this time, the wound was closed in layers with interrupted closure. There wer eno oprhopedic complications throuhout this procedure and he left the room in stable condition.

The codes the physician wants to code are: 23410, 23130, 23430
What I see is: 23430, 23130

Please see what anyone else can get? I am truly frustrated with this one.
Thanks


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## Bella Cullen (Jul 9, 2010)

Anna Weaver said:


> I would like someone else to review this report for me please and see what you get for codes. I must confess to having difficulty with this physician and I'm not sure if I'm being "nitpicky" as he states or if I clearly don't understand what he's trying to say. I see where he exposed and excised the coracoacromial ligament and bursa, I see where the rotator cuff was identified, I see where the biceps tendon was repaired, I do not see where he mentions correcting the rotator cuff. He told me I was nitpicking and that it was very clear for any other surgeon to see. Maybe it's just my difficulties with this physician that makes it unclear to me? Would like your honest opinions please. If I'm wrong, I want to get myself back on track.
> 
> Preop Dx: rotator cuff tear, right shoulder, impingement syndrome with type 3 acromion and degenerative OA of acromioclavicular joint, right shoulder., 90% partial tear of the long head of the biceps tendon at the right shoulder.
> 
> ...



I will just copy and paste what I see for the rotator cuff repair. 

After having this part of the surgery done, the rotator cuff was identified. It was* torn *not only *longitudinally from the infraspinatus*, but also it was *totally detached from its footplate on the greater tuberosity*. 

*The footplate of the humerus was cleaned out and prepared for the *acceptance of the anchor *sutures*. The *longitudinal part of the tear *was *repaired with non-absorbable ethibond *and then placing three *anchor sutures *strategically, fiber wire sutures were passed through the tendon and the tendon was reduced over the *tuberosity* and was tightened. Using swivelock technique, a *second row repair *was perfomred on the side of the humerus. *At the end repair was fantastic*.

I would bill for all three procedures.


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## Anna Weaver (Jul 9, 2010)

Thank you so much. I appreciate your feed back. Now, I see what he was talking about. I appreciate it.


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## malery (Jul 12, 2010)

Hi, You should be careful that 23130 doesnt get bundled into 23420. Most payers consider it inclusive. Also if it was a chronic issue you should look at code 23420 which includes the acromioplasty in its RVU's. It's better than having to write it off due to inclusive. Code 23430 is seperate any way you go.


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## Bella Cullen (Jul 13, 2010)

malery said:


> Hi, You should be careful that 23130 doesnt get bundled into 23420. Most payers consider it inclusive. Also if it was a chronic issue you should look at code 23420 which includes the acromioplasty in its RVU's. It's better than having to write it off due to inclusive. Code 23430 is seperate any way you go.



But she isn't billing 23420 so there wouldn't be a reason for 23130 to get bundled into it. 
three codes being billed are 23410, 23130, 23430 and those codes are all separately reimbursable per AAOS the only thing is 23130 needs a 59 mod when billed with 23410 per AAOS CCI edits.


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## Anna Weaver (Jul 13, 2010)

thanks, I have had discussions concerning the 23410 and 23130 with this physician already. He swears by the AAOS and no other sources. So, we agree to disagree with this one. We bill it and I add the 59 modifier and I keep notes that I disagree with this billing. The acromioplasty is done to get to the rotator cuff in 99% of his cases, but that's another story! 
Thanks for everyone's feed back. I appreciate this.


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## malery (Jul 14, 2010)

Oops...
I did mean to state that 23130 could be inclusive per CCI of 23410 not 23420 sorry about the typo, but I agree adding modifer 59 is a great way to go.

I thought 23420 was something worth looking into if it was chronic.

AAOS is a reliable resource and they have helped me with many appeals.

Again, sorry about the typo, fast fingers.


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## Bella Cullen (Jul 14, 2010)

Anna Weaver said:


> thanks, I have had discussions concerning the 23410 and 23130 with this physician already. He swears by the AAOS and no other sources. So, we agree to disagree with this one. We bill it and I add the 59 modifier and I keep notes that I disagree with this billing. The acromioplasty is done to get to the rotator cuff in 99% of his cases, but that's another story!
> Thanks for everyone's feed back. I appreciate this.



Well I believe 23410 and 23130 is separately billable because if you read the description in the coders desk reference under these codes for 23130 it says: A partial acromioplasty or acromionectomy *with or without coracoacromial **ligament release* is done. This procedure is also commonly performed during repair to the rotator cuff in an effort to increase the space below the acromion where the cuff tendons traverse toward their insertion on the humerus. Dissection is carried down to the acromion. Acromioplasty involves the division of the acromioclavicular ligament followed by the use of a burr to cut away the under surface of the acromion....
then for 23410 it says:
the physician repairs a ruptured rotator cuff. A longitudinal incision is made along the anterior portion of the shoulder and the skin is reflected. the deltoid fibers and the underlying tissues are divided. The coracoacromial ligament is divided and the supraspinatus tendon is detached by a traverse incision along the greater tuberosity. the distal frayed edges of the tendon are removed....blah blah blah. 
23410 does not mention in the coders desk reference anything about acromioplasty or dissection carried down to the acromion. 
and 23130 says is commonly performed during repair to the rotator cuff. So that is my arguement as to why these codes are billable together.


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## Anna Weaver (Jul 14, 2010)

I did not mean to imply that the AAOS was not a reputable source. My comment was meant to reflect the fact that this physician in particular will not accept anything other than AAOS. no reflection against anyone or anything meant there. I also use them as references on occasion, but not to the exclusion of all others. 
When I researched this topic before (23410/23412 with 23130) I found that almost every other source felt it was inclusive. There are of course arguments that will go either way.


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## Bella Cullen (Jul 14, 2010)

Anna Weaver said:


> I did not mean to imply that the AAOS was not a reputable source. My comment was meant to reflect the fact that this physician in particular will not accept anything other than AAOS. no reflection against anyone or anything meant there. I also use them as references on occasion, but not to the exclusion of all others.
> When I researched this topic before (23410/23412 with 23130) I found that almost every other source felt it was inclusive. There are of course arguments that will go either way.



I didn't take anything you said as anything bad. I just wanted to tell you my take on those two codes and why I think they are not inclusive so then maybe you could see another persons point of view rather than just that physician that gives you a hard time. 
Because sometimes when physicians won't listen to anything you have to say it makes people automatically want to prove them wrong, so that is why I wanted to give my opinion on the topic just so you have someone else to go by. 
I'm sorry if you took anything I wrote the wrong way. I was just trying to help. 
That is the bad part of typing because things get interpreted wrong sometimes.


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## Anna Weaver (Jul 15, 2010)

Understood and I didn't take it wrong. Thanks for your opinions. You are right, sometimes I don't see what he's trying to say. We have a complete breakdown of communications between us and it makes me crazy. Out of the 30 or so physicians we have, he's the only one with whom I have this issue. So, I have to try and figure a way around it without my feelings getting in the way. Hard to do sometimes, but it happens.
Anyway, Thanks again. I do appreciate your feed-back.


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