Orthopedic Coding Alert

Scrutinize the op report to determine whether the physician used a tissue scaffolding device.

If your orthopedic surgeon documents using a tissue scaffold such as the GraftJacket, Conexa or another similar implant during rotator cuff repairs, you may find yourself in a coding quagmire — CPT® does not include a code for the tissue scaffolding procedure, but the physician thinks that the extra work is worth more than a standard rotator cuff repair.

You can code RCRs with tissue scaffolding like a pro, even if you’re a first-timer. Read our experts- advice and find out just how to get your coding on the straight and narrow.

Recognize Tissue Scaffolding in the Documentation

The first step in determining whether your surgeon performed a tissue scaffolding procedure is to examine the op note. For example, the physician might refer to an “acellular dermal matrix,” “GraftJacket,” “GJA,” “Restore implant,” or “tissue scaffold” when explaining the procedure he performed.

The GraftJacket is made from the processed human skin by removing the cells and using a special freeze-drying technique. Once it is rehydrated, the graft is extremely strong and very resistant to suture pull out, which is why surgeons choose it with complex rotator cuff repairs and reconstructions. 

During the procedure, the physician sutures the implant to the remaining stump of the cuff tendon and to the surrounding remaining tissues. It is attached to the bone using standard suture anchor techniques. If there is any remaining native cuff tissue, it can be repaired as well and the GraftJacket will support it during the repair.

Start With the Right Diagnosis Code

When you’re faced with an op note for a rotator cuff repair using the GJA, you’ll almost always report one of the following ICD-9 codes for a torn rotator cuff, depending on whether the injury is traumatic or nontraumatic:

• 840.4 — Sprains and strains of shoulder and upper arm; rotator cuff (capsule) 
  
• 727.61 — Rupture of tendon, nontraumatic; complete rupture of rotator cuff. 
  

Usually the cuff is so bad that nothing else (outside of an artificial joint or a major muscle transfer) will help. These patients most often have very severe atrophy of their muscles, chronic pain and weakness. In addition, most of these patients have had previously failed surgery.

Pin Down the Right CPT® Code

If your surgeon documents a rotator cuff repair with tissue scaffolding, you should report the appropriate rotator cuff repair code, such as 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]), experts say.

If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of code 23420. If fascia or synthetic material is required, code 23420 is also appropriate, experts say.

In addition, the AMA’s publication CPT Assistant states, “CPT® code 23420 is intended to identify an old tear. This type of extreme tear usually requires rearrangement of the normal anatomy and sometimes grafting with either biological or nonbiological material for repair.”

Arthroscopic option: If the surgeon performs the RCR with tissue scaffolding as an arthroscopic procedure, you should report 29999 (Unlisted procedure, arthroscopy), since there is no arthroscopic counterpart to code 23420, says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

If the surgeon performs this procedure and finds it significantly more difficult or time-consuming than a standard RCR with tissue scaffolding application, you may be justified in appending modifier 22 (Increased procedural services) to 23420. However, you cannot add modifier 22 to every tissue scaffolding claim — the surgeon must explain why he thinks the procedure went above and beyond a normal reconstruction.