Orthopedic Coding Alert

Know how your provider might diagnose, treat these injuries.

When your orthopedist treats a patient with a rotator cuff (RC) injury, there will be a lot for the coder to untangle. There will be separate codes for diagnosis and treatment — and don’t forget about the ICD-10 codes for symptoms and conditions that will accompany the encounter.

Miss even one of these components, and you could be in for all sorts of potential trouble: upcoding, downcoding, denials, etc.

Help’s here: We talked to some experts about best practices for coding your orthopedist’s services for patients with rotator cuff injuries. Here’s what they had to say.

Diagnostic Can Involve E/M, MRI

Normally, the provider will start with an office/outpatient evaluation and management (E/M) service visit when a patient has a potential RC injury. That often leads to an imaging study, most likely a magnetic resonance imaging (MRI).

Potential codes: Services your orthopedist provides for a patient with a potential RC injury could be represented by the following codes:

E/M:

99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.)

MRI

• 73000 (Radiologic examination; clavicle, complete)
• 73010 (… scapula, complete)
• 73020 (Radiologic examination, shoulder; 1 view)
• 73030 (… complete, minimum of 2 views)
• 73221 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s))
• 73223 (… with contrast material(s))

Caveat: “Oftentimes when patients have an RC tear, they will also have a long head of the biceps tear and/or labrum tear,” explains Wayne Conway, CPC, CGSC, COSC, senior physician coding specialist at WakeMed Physicians Practice in Raleigh, N.C.

Because of the anatomy of the biceps/labrum tear, RC tears could be hidden by these injuries. If either of these injuries occurs with a RC tear, the orthopedist might miss it on first look.

This might result in repeat MRIs, E/Ms, or even other imaging services to pinpoint a RC injury. When more extensive means are necessary to diagnose a RC injury, be sure to code properly and always to the notes.

Look for These Symptoms on Potential RC Injuries

When a patient reports to the orthopedist with a potential RC injury, “typical complaints consist of above the head movements of arms that will likely cause pain. Reaching behind the back will hurt, as well. When reaching out with arms extended trying to raise objects, weakness is experienced,” explains Conway.

Confirmed RC Injury Could Lead to These Surgeries

When the orthopedist does diagnose a RC injury, they’ll likely move on to surgery next. You’ll report RC repairs with the following codes, Conway confirms:

• 23410 (Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute)
• 23412 (… chronic)
• 23420 (Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty))
• 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)

Breakdown: Consider this explanation from Conway: “RC repairs can be coded with codes 23410, 23412, or 23420 if performed open. Code 23410 would be used if the tear was an acute tear. Code 23412 would be used if the procedure was performed open and was chronic in nature.

“Use of code 23420 would need to involve more than your average repair. One example for billing code 23420 may be the repair of three RC tendons, as this involves a reconstruction and not a repair. If the RC repair is performed arthroscopically, you would bill code 29827. This code can be used for acute or chronic tears.”

Takeaway: Be prepared to use any of the above codes for RC repair, but you’ll see more of two than the others. “Most of the RC repairs I code are arthroscopic, so they’d be 29827. Sometimes ‘mini-open’ chronic disease tear, 23412. Rarely 23410 or 23420,” says Ken Camilleis, CPC, CPC-I, COSC, educational consultant at Superbill Consulting Services.

Remember Modifiers to Solidify Coding

You might need to use one (or all) of the following modifiers when coding for a patient with an RC injury:

• Use modifier 57 (Decision for surgery) on any significant and separately reportable E/M that precedes and leads to RC surgery.
• Use modifiers 59 (Distinct procedural service) and/or 51 (Multiple procedures) if certain surgeries/procedures accompany the surgical RC repair.
• Use modifier 26 (Professional component) if you are only coding for your orthopedist’s services, not the equipment used during the service. (For example, they interpret a shoulder MRI using a local hospital’s equipment.)
• Use modifiers LT (Left side) and/or RT (Right side) to indicate laterality on RC repairs. (For example, the surgeon performs arthroscopic surgical RC repair, you’d report 29827-RT.)

Look out for These RC-Related ICD-10 Codes

When looking at ICD-10 codes that might prove medical necessity for the above RC repair codes, things get a little opaque. There are no Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs) for codes 23410, 23412, 23412 or 29827, Conway confirms — meaning there is no definitive list of approved ICD-10 codes for this quartet of codes.

You’ll also be without official guidance when you’re providing diagnosis codes for any E/M, MRI, or other service related to the eventual RC repair.

There are, however, some codes that seem to pop up often in and around RC repair claims. Here’s a list of codes you might see on your coding journey from diagnosis to surgery:

• M24.11 (Other articular cartilage disorders, shoulder)
• M25.511 (Pain in right shoulder)
• M25.512 (Pain in left shoulder)
• M25.519 (Pain in unspecified shoulder)
• M75.11- (Incomplete rotator cuff tear or rupture not specified as traumatic)
• M75.12- (Complete rotator cuff tear or rupture not specified as traumatic)
• S46.011- (Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder)
• S46.012- (Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder)
• S46.019- (Strain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder)
• S43.43 (Superior glenoid labrum lesion)

Note: This is not a definitive list of ICD-10 codes for RC repair; nor is it a list of approved codes for RCR. Always code to the notes, and check with your provider or payer if you have any questions about diagnosis coding as it related to RC repair.