Orthopedic Coding Alert

Provider will use MRI/E/M combo to diagnose.

Coding a series of encounters in which the physician diagnoses and repairs a torn rotator cuff will take some acumen, as the surgery is almost always preceded by other services. If you cannot identify all of the codeable services and apply the proper modifiers to the claims, you’ll be selling your practice short (bad) or overbilling the payer (worse).

Don’t worry, though. We’ve got two experts to take use through the process, from diagnosis to surgery. Wayne Conway, CPC, CGSC, COSC, senior physician coding specialist at WakeMed Physicians Practice in Raleigh, N.C.; and Nate Felt, MS, CPC, ATC, PTA, gave us some inside info on shouldering the coding load on rotator cuff repairs.

Here’s what they had to say.

Achieving Dx Can Mean E/M, Imaging

The first step toward repairing a torn rotator cuff is diagnosing one. Typically, the orthopedist will perform a magnetic resonance imaging (MRI) during an office evaluation and management (E/M) service to determine if a tear exists, Conway explains.

If the surgeon performs an office E/M, you’ll choose a code from the 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) code set to represent the E/M. You’ll code shoulder MRIs with 73040 (Radiologic examination, shoulder, arthrography, radiological supervision and interpretation).

Modifier(s) alert: You will need some modifier help on these diagnostic encounter claims. If the E/M and/or MRI ends up leading to rotator cuff surgery, you’ll append modifier 57 (Decision for Surgery) to the E/M to show that it was a separate service from the tear repair (all rotator cuff repair codes are major surgeries, which means that you would use modifier 57 for any separate E/Ms. If the E/M and/or MRI lead to a surgery with a minor (0- or 10-day) global period, you’ll append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M.

Also, the payer might want laterality specified in the claim, in which case you’d append modifier LT (Left Side) or RT (Right Side) to 73040, depending on encounter specifics. Finally, if your practice does not own the MRI equipment the surgeon uses, you’ll append modifier 26 (Professional Component) to 73040 to show you are only coding for your surgeon’s services, not the use of the equipment.

Caveat: Even with so thorough a process, surgeons can miss a rotator cuff tear.

“With an MRI, tears are sometimes missed. Many times when patients have a rotator cuff tear, they will also have a long head of the biceps tear or labrum tear. The biceps tear is often seen on a MRI, but many times a labral tear is missed on a MRI due to the anatomic location. The labrum sits between the glenoid and the humeral head of the humerus,” explains Conway.

Best bet: If it appears the surgeon used more extensive means of finding a torn rotator cuff — such as a repeat MRI or another imaging procedure or E/M — be sure to code accordingly. As always, consult with your payer if the diagnosis services related to the surgery seem to mark you as an outlier.

Choose From These Codes for Surgery

Once your surgeon diagnoses a rotator cuff repair they’ll perform surgery, which will lead the coder to another choice. “The three most common [rotator cuff] procedures: open, mini-open and arthroscopic,” explained Felt during his “Mastering Orthopedic Coding” session at HEALTHCON 2020. It’s also of vital importance to identify whether the tear is chronic or acute, both for diagnosis and CPT^® coding, Felt explained. A chronic condition usually involves more than three months of symptoms with no acute accident or episode.

Conway offers a rundown of the quartet of repair codes you’ll likely choose from for most rotator cuff repairs:

• 23410 (Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute). “Code 23410 would be used if the tear was an acute tear and should be diagnosed with a ‘S’ code,” such as S46.00- (Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of shoulder), Conway explains.
• 23412 (Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic). “Code 23412 would be used if the procedure was performed open and was chronic in nature,” says Conway. This is the “mini-open” repair that Felt mentioned during his presentation.
• 23420 (Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)). “Use of code 23420 would need to involve more than your average repair. One example may be the repair of three rotator cuff tendons for billing code 23420, as this involves a reconstruction and not a repair,” according to Conway. You should use an “M” code, such as M75.112 (Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic), with this CPT^® code.
• 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair). This code can be used for acute or chronic tears.

Modifier alert … again: Payers might want laterality indicated on the claim; if that’s the case, be sure to append modifier LT or RT to the repair code, depending on encounter specifics.

Conway says that there are no local coverage determinations (LCDs) or national coverage determinations (NCDs) on the books listing acceptable diagnosis codes for 23410, 23412, 23420, and 29827; he does think that if the cuff repair code “is not accompanied by a rotator cuff tear [ICD-10] code, it will get denied.”