# Shoulder hemiartroplasty



## ortho1991 (Jul 13, 2009)

Hi everyone

I hope someone can help.  Our Dr. billed 23470 hemiarthroplasty shoulder
23412 rotator cuff repair, 23430 biceps tenodesis and 20680 removal of hareware.

Our local medicare carrier paid 23470 and 20680, and disallowed 23412 rotator cuff repair,23430 biceps tenodesis.  Our doc. things he should be paid for all these codes. Here is the op-note in short form.

OP note  An incision  was made from the coracoid process of the RT shoulder approximateley 4-5 cm. Dissection was taken down to the subscapularis, borad spect interval, and and an open retractor was then placed on the conjoint tendon.  The subscapularis was intact, bicipital groove was identified.  It was then opened.  The biceps tendon was then released and then subsequently tenodesed through the pectoralis in a subpectoral repair, and soft tissue tenodesis with mulitple figure of 8s.  The lesser tuberosity was then osteotomized with full mobilization of the subacapularis.  The humerus was quite deformed, multiple ridges from the previous proximal humerus fractue, and there was still, however, supraspinatus and infraspinatus superiorly, was quite degenerative but actually reduced about half way over the footprint.  I then placed four Mason-Allens with #2 FiberWire through the supra and infraspinatus to be able to bring this back to the tuberosity.  I then identified as normal as possible the appropriate position, both on inclination and inversion of the humeral head.  I then subsequently using and oscillating saw, osteotimized and then tried to cut this in such a way that it would be if anything 140 to 150 degrees, and placed a small sten in a slightly valgus position to gain almost surpeior cuff tear arthropathy cap.  With this in place, I then removed all osteophytes.  The posterior cuff was intact.  I then subsequently used my broaches and felt I got the 6.5  easilty down but with some difficulty, and felt that a 6.5 x120 tilted in valgus was able to achieve this, my appropriate inclination.  I chose the 140 based on the fact that my cut was almost about 150 degrees.  When I put the 140 in using the 6.5 I was able to sit at the 150 osteotomy.  I then chose the head, a 43x1 6.  With this in place, I templated this, placed the stem and felt that this had with the setting of 2, was the most appropriate for the appropriate overage.  With this in place, I then placed my distal cement restricter, I then placed two patches of PaliCoast cement, finger packed it for pressurize, and then place the #140x6.5 by 120 at a 140 degree angle down with the appropriate position with excellent anatomic reduction of the head.  All excess cement was then removed.

Prior to doing this, however, I placed the four deep sutures of my Mason-Allens through the greater tuberosity to be able to tie this down after the head was installed.  I then subsepuently placed three #5 Ethibonds around the osteotomy site, around the lateral humerus to be able to cerclage around the lesser tuberosity osteotomy.  Once the cement was hardened,  I then repaired my supra-infraspinatus, repaired my subscapularis using the cerclage sutures as well as the sutures from the humeral head as well.  Once this was complete, the incisions were closed.  

This medicare's payment correct?  Should I have used a modifier 59?  Not sure if justified.

*Please any suggestion or advise will be greatly appreciated*

Thank you in advance for your help


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## martnel (Jul 13, 2009)

I would add -59 to 23412 and leave out the 23430. (Using CodeX Software)


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## vikas.maheshwari (Jul 14, 2009)

According to CCI edit put modifier 59 along with CPT 23412 and 23430.

Thanks,


Vikas maheshwari
MBA-HCS, CPC-H


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## ortho1991 (Jul 14, 2009)

Thank you for your help I will try the 59 modifier


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