# RC repair w/acromioplasty?



## BFAITHFUL (Aug 24, 2010)

Need some help with the following:

Doc wants to bill just 23130 & 23120......but Im thinking 23412, no 23130(bundled) and no 23120 bcuz no size of distal clavicle resection is mentioned

DX:  right shoulder impingement syndrome (726.2), degenerative arthritis of AC (715.31)

Procedure: Subacromial decompression & bursctomy of right shoulder, lateral clavicle resection. & repair of partial thickness tear of the supraspinatus tendon 

26 year old female with impingement syndrome of the right shoulder.  The patient had failed to improve despite the use of antiinflammatories, corticosteriod injection, and extensive course of physical therapyl  She did have an MRI which revealed evidence of impingement syndrome and synovitis of the AC joint.  the patient after failing to show improvement with conservative management was indicated for surgery.  

The proposed incision site over the anterior aspect of the acromion and clavicle was marked out and injected with 1% lidocaine with epinephrine.  A linear incision was centered over this anterior and lateral aspect of the acromion and brought medially.  A bovie electrocautery was used throughout the case for hemostasis.  Upon obtaining the clavipectoral fascia, the plane was developed to create a mobile window and the Bovie electrocautery was used to perform deltoid on full thickness ablation of the deltoid tendon off of the acromion and the lateral clavicle.  The anterior aspect of the acromion was noted to have a type II acromion and a Darrach retractor was inserted undersurface the coracoacromial ligament resection.  The anterior aspect of the acromion was then resected with the oscillating saw and a darrach retractor was then further inserted under the acromion and the undersurface of the acromion was resected with the oscillating saw.  Followed by use of the oscillating foot rasp to smooth the roughened edges down great care was taken to ascertain that the resection and dcompression then performed to the lateral most aspect of the acromion.  The lateral clavicle was inspected and there was noted to be hypertrophic spurring along the inferior aspect and this was debrided with the oscillating foot rasp followed by resection of the lateral aspect of the clavicle with the oscillating saw followed by use of the oscillating foot rasp.  At this point, a bursectomy was performed.  There was notd to be over the supraspinatus tendon at the anterior aspect of the acromion and partial thickness tear of the superior surface of the supraspinatus tendon.  This was not a full thickness tear.  A 2-0 PDS suture was used in a figure of eight fashion to reapproximate this defect.  The remainder of the cuff was inspected and found to be intact.  The subscapularis and infraspinatus tendons were all noted to be intact and a glove finger was inserted and no further adhesions were appreciated.  

thank you


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## BFAITHFUL (Aug 27, 2010)

any takers on this one?


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## Bella Cullen (Aug 31, 2010)

BFAITHFUL said:


> Need some help with the following:
> 
> Doc wants to bill just 23130 & 23120......but Im thinking 23412, no 23130(bundled) and no 23120 bcuz no size of distal clavicle resection is mentioned
> 
> ...



For this one I would code this as 23130 and 23120 because I don't really think there is enough to code 23412 for this specific case.  And you don't need a specific size of the clavicle removal, because 23120 is for PARTIAL removal so just part of it is fine. 

Also, for future reference...23412 can be billed with 23130 and 23120...they are NOT bundled into 23412. This info is per the AAOS codeX software for 2010.


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## BFAITHFUL (Sep 7, 2010)

I remember reading specifically CPT 23130 is bundled into 23412 per CCI edits and even though AAOS doesn't have 23130 as being bundled with 23412 there are still certain criteria that needs to be met..  for example " documentation of coplaning, or
changing a type II or type III acromion to type I....that is the
recommended documentation by AAOS.

Because so many carriers/payers are now bundling the acromioplasties
with rotator cuff repairs (RCR), it is getting harder to these paid. There are 
basic 4 things that are part of an
acromioplasty. Notice that three of those things are also part of the
RCR:

4 Parts of an Acromioplasty:

*       1 - Excision of the CA Ligament

-       Part of a RCR

*       2 - Excision of bursa, deposits, etc

-       Part of a RCR

*       3 - Cleaning of the AC Joint

-       Part of a RCR

*       4 - Bony work on the Acromion

-       NOT part of the RCR - can you support??

 - so they are looking for physician documentation of that bony work,
not excision of osteophytes, CA release, etc. Key: You need to document
changing the shape of the acromion. 

I have seen some great documentation examples, like: "I converted a type
III acromion to a
type I using ....."

or

"There was significant co-planing of the acromion due to sloping and XX
amount was removed" 

Carriers are really looking for size, work, tools, etc.  It is going to
come down to documentation of where the of the 'bony' work is being done
on the acromion to get reimbursed for 29826 or 23130.

AAOS states:

29826 Arthroscopy, shoulder, surgical; decompression of subacromial
space with partial ACROMIOPLASTY, with or without coracoacromial release

& According to CPT assistant and AAOS guidelines they both agree that size of distal clavicle resection does need to be documented at least 8mm-10mm to prove that this is just not removal of osteophytes/spurs

*CPT Knowledge Base Vignette:

CPT 29824/23120*

Following adequate exposure of the distal end of the clavicle, a motorized burr is introduced through the anterior portal and approximately 8-10 mm of the distal end of the clavicle is removed circumferentially. Intraoperative x-ray may be obtained to ensure distal clavicle has been adequately resected. The subacromial space and the area of the resected AC joint are injected with a mixture of Marcaine and morphine. The portal sites are closed with one or two stitches.

*AAOS*:

If part of the excision of the distal clavicle was through the open wound, then code 23120 is appropriate. The American Academy of Orthopedic Surgeons (AAOS) committee on CPT coding has agreed that excision of 1 cm or more of the distal clavicle is required before use of partial claviculectomy code (23120). Excision of a small osteophyte on the under-surface of the distal clavicle should not be considered a partial claviculectomy


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## Bella Cullen (Sep 8, 2010)

BFAITHFUL said:


> I remember reading specifically CPT 23130 is bundled into 23412 per CCI edits and even though AAOS doesn't have 23130 as being bundled with 23412 there are still certain criteria that needs to be met..  for example " documentation of coplaning, or
> changing a type II or type III acromion to type I....that is the
> recommended documentation by AAOS.
> 
> ...





Below is from the AAOS 2010 codeX for cpt 23412, It specifically says Intraoperative services *NOT* included in the global service package: and under that are the codes 23130, 23120.
Also, if you read the description in the coders desk reference under 23412 it does not say anything about the acromion. and for 23130 it states this procedure is also commonly performed during repair to the rotator cuff. 

(But anyway for your specific case that you were questioning I would just bill 23130 and 23120 because I don't really think there is enough to code 23412).

*CPT Code: 23412*

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

Intraoperative services included in the global service package:

	1.	local infiltration of medication(s), anesthetic, or contrast agent before, during, or at the conclusion of the operation
	2.	suture or staple removal by operating surgeon or designee
	3.	surgical approach, with necessary identification, isolation, and protection of anatomic 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
	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, glenohumeral joint (eg, 23040, 23100, 23105, 23107)
	13.	deltoid reattachment to acromion
	14.	excision of bursa or calcium deposits (eg, 23000)
	15.	excision of acromioclavicular joint osteophyte(s)
	16.	mobilization of local tissue for rotator cuff repair
	17.	manipulation, shoulder (eg, 23700)
	18.	diagnostic arthroscopy, shoulder (eg, 29805)

Intraoperative services *not included *in the global service package:

	1.	supplies and medication (eg, code 99070, HCPCS Level II codes)
	2.	insertion, removal, or exchange of nonbiodegradable drug delivery implants (eg, 11981–11983)
	3.	excision of distal clavicle (eg, *23120, 29824*)
	4.	partial acromioplasty (eg, *23130, 29826*)
	5.	coracoacromial ligament release (eg, 23415)
	6.	biceps tenodesis (eg, 23430, 29828)

Medicare global fee period: 90 days


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## BFAITHFUL (Sep 19, 2010)

yes..... I have that exact information in my Global Data Service book from AAOS but just because something is stated as not being inclusive or bundled it doesn't mean there's not documentation requirements that need to included in the operative report... the information posted above is the required documentation that comes directly from AAOS one of the physicians on the committee....

For example....under CPT 29880 or 29881 one of the procedures that is stated as not being inclusive/intraoperative is CPT 29877 but if the menisectomy is done on the medial compartment of knee and the chondroplasty is also done in the medial compartment then it cannot be separately billed even though it states "NOT inclusive" to CPT 29880/29881... You see there are documentation criteria that needs to be met.... However if this chondroplasty CPT 29877 was performed in the lateral compartment then it can be billed separately using modifier 59..

In addition.... the information you posted above under "INCLUSIVE" doesn't all need to be documented for a Rotator Cuff repair...  the AAOS is just stating that if any of the following procedures are performed during CPT 23412 then that would be inclusive.


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## BFAITHFUL (Sep 19, 2010)

Also... the information from CPT assistant & AAOS regarding there needs to be documentation as far as the size of distal clavicle having to be documented.... So i have two great official sources...   but where do you base your opinion on still being able to bill for CPT 23120... what official resources do you have?   when clearly they state differently..???


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## Bella Cullen (Sep 21, 2010)

BFAITHFUL said:


> Also... the information from CPT assistant & AAOS regarding there needs to be documentation as far as the size of distal clavicle having to be documented.... So i have two great official sources...   but where do you base your opinion on still being able to bill for CPT 23120... what official resources do you have?   when clearly they state differently..???



First of all if you already know the answer or do not want to take someone elses opinion then why did you ask a question. 
Second the ortho doc i work for always does arthroscopy sub acromial decompression 29826 and distal clavicle resections 29824 and I always bill those together. Even sometimes with an open rotator cuff repair 23412. 
And the open codes for those are 23130 and 23120. 

Oh and from what I have from an ortho seminar put on by kelly, sloan, and associates it states the AAOS *suggests*, NOT requires, that documentation of greater than 1.0 cm removed should be documented. 
And from everything I was taught or by AAOS, Ingenix coders desk reference, ortho coders pink sheets or seminars, even Medicare CCI Edits it never said 23130, and 23120 are bundled and not billable together. 

And I know all about 29880 and 29877 that they have to be done in separate compartments. 
I was just giving you a resource on the shoulders for an example so sorry if i was trying to help you but you obviously know the answer so thanks for wasting my time.


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## BFAITHFUL (Sep 22, 2010)

that's not at all what I was trying to do and so sorry if you took it that way.... I was just simply trying to see what resources you used that led to your decision.. As far as me already knowing that answer... I wouldn't have posted this inquiry if I was sure about my answer.  I've just heard so many different responses as far as coding for 29824/23120 needing the size of distal clav. resection and now according to CodeX program this reference is not listed any longer & this is why I was confused. 
& I was also confused on billing the RC repair..wasn't sure if there was enough documentation & this is also why I posted this inquiry, but since then I was given the advice by two Audit consultants including (Heidi Stout, one of the editors from Orthopedic Coding Alert) that I can definitely bill 23412.  
and with the 23130... I was also told there needs to be documentation requirements to be able to bill this with CPT 23412 which has to include bony work being done to code this with a RC repair if we are to use modifier 59 for those carriers who use the CCI edits & not AAOS.    

Please don't take this the wrong way.. but when audited by insurance carriers these guidelines by AAOS and other resources is what they use to determine whether or not the documentation requirements were met so these "suggestions" are extremely important when it comes down to proper documentation.  

Again I didn't mean to sound unappreciative of you providing your opinion.. 
I'm very passionate about coding as I'm sure you are as well and sometimes... well.. we can become a bit heated on certain subjects... that's all.  

Thank you


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