Orthopedic Coding Alert

Knowledge of anatomy is crucial

When you have a solid idea of where the shoulder parts are located and how they fit together, reporting a rotator cuff repair (RCR) is easy. The rotator cuff is a series of four muscles that surrounds the gleno-humeral joints -- almost completely. The muscles are:

- Subscapularis

- Supraspinatus

- Infraspinatus

- Teres minor.

The subscapularis is the largest muscle and is anterior. The supraspinatus is the muscle most commonly torn and is superior. The infraspinatus and teres minor are the posterior muscles.

The term -the rotator interval- is the antero-superior space between the anterior edge of the supraspinatus and the superior edge of the subscapularis, and is the only space where the rotator cuff doesn't completely invest the gleno-humeral joint.

The interval between the supraspinatus and the infraspinatus is often termed the -posterior rotator interval,- and physicians sometimes have difficulty telling where one muscle tarts and one ends when performing arthroscopic surgery.

Learn these seven CPT codes for RCR:

- 23130 -- Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release

- 23410 -- Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute

- 23412 -- - chronic

- 23415 -- Cocacoacromial ligament release, with or without acromioplasty

- 23420 -- Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

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

- 29827 -- Arthroscopy, shoulder, surgical; with rotator cuff repair.

Look at the Options When Coding RCRs

Since the late 1990s, surgeons have been able to perform arthroscopic rotator cuff repairs. Some doctors, not yet fully versed in arthroscopic techniques or for matters of personal preference, perform a -mini-open rotator cuff repair.-

In this technique, the surgeon performs an arthroscopic acromioplasty and prepares the cuff edges and bony attachment arthroscopically. The physician then makes a small incision, often only 1.5-3 centimeters, and repairs the tendon using bony suture anchors.

Know Acute and Chronic Repairs

For open procedures, you may be confused as to when you should use 23410, 23412 or 23420. Part of this depends on the definition of -acute.-

For most coding situations, -acute- describes an injury less than three months old. Unless your surgeon specifically documents that the patient's injury occurred less than three months from the date of surgery, you probably use 23412 in most cases.

But When Would You Use 23420 for Open Repairs?

There are no hard and fast guidelines. One thing to remember is that more than one rotator cuff tendon can be torn. These are often termed as two-tendon tears or three-tendon tears, and rarely four-tendon, or massive, tears -- although those are often irreparable. Use 23420 for any multi-tendon repair, which needs to be documented by the surgeon. There is no extra code for repairing more than one tendon. Report 23420 only for those repairs.

When Can You Also Code the Acromioplasty?

With open repairs, you really can't as of 2006. As noted above, by definition 23420 includes the acromioplasty. And as of 2006, the National Correct Coding Initiative (NCCI) edits bundle 23130 into 23410, 23412 and 23420. Prior to 2006, you could separately code 23130 with 23410 and 23412.

Choose Between Open, Arthroscopic or Both

Billing for open codes as well as an arthroscopy can be confusing, but there are times that you can correctly bill for both. The trick is that both procedures are planned and necessary. For example, suppose the physician schedules an arthroscopic subacromial decompression (29826) and an open rotator cuff repair (23412) during the same operative session, and she justifies the reasons for the separate approaches in her operative notes. You should bill both codes.

But if the physician schedules only an arthroscopic procedure, such as 29826, and then converts to an open procedure mid-surgery, you would only report the code for the open procedure.

For instance, the physician schedules the patient for an arthroscopic rotator cuff repair of a chronic tear, with intent to bill 29827. But upon establishing the portals and viewing the rotator cuff through the scope, she decides she needs to perform an open repair. In this case, you can't report both the arthroscopic repair and the open repair.

You should only bill for the repair method the physician actually accomplished (in this case, 23412).

The only time this wouldn't stand true is if the physician performs a diagnostic arthroscopy to find out the nature of the problem, and decides that the only way to repair the condition is through an open repair.

Tip: When the doctor performs a diagnostic arthroscopy and discovers she must perform an open repair of a previously unknown condition, you can report both the open repair code and the diagnostic arthroscopy code by appending the 59 modifier (Distinct procedural service) to the diagnostic arthroscopy. Some carriers might reject the claim for one procedure or the other, but if the physician performs and documents the work, you should ask for the reimbursement.