Orthopedic Coding Alert

Question: Our surgeon repaired the deltoid muscle as an open procedure. We're considering 23410, but we don't think that it's close enough. Can you suggest a better code?


Tennessee Subscriber

Answer: Unless the surgeon specifically documented a musculotendinous cuff repair, you should not report 23410 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; acute).

Because your surgeon repaired the deltoid muscle, you should consider 24341 (Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary [excludes rotator cuff]). Compare this code's descriptor to your surgeon's documentation to confirm that it describes his services.