Orthopedic Coding Alert

Question: The orthopedic surgeon completed an I&D for postoperative infection through an existing incision and revision of rotator cuff reconstruction due to re-tear (3 weeks after the original surgery). What codes and modifiers are correct?

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Answer: For the irrigation and drainage, report 23030 (Incision and drainage, shoulder area; deep abscess or hematoma) and append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). Pair the procedure with diagnosis code 998.59 (Other postoperative infection).

The correct reconstruction code hinges on the type of procedure originally performed. Your most likely choices are 23412 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic) or 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]). Append modifier 76 (Repeat procedure or service by same physician); then include diagnoses 998.31 (Disruption of internal operation surgical wound) and 727.61 (Rupture of tendon, nontraumatic; complete rupture of rotator cuff).