Orthopedic Coding Alert

Question: Our surgeon wants to report two units of 23410 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; acute) for repairs done in same shoulder. There were tears of both the teres major and latissimus dorsi. Repair was done through a single incision for full thickness of tears of 90% of the tendon with a very small slip of the upper border of the tendon remaining attached.

The operative note reads as follows:

“A curvilinear incision was made cephalad to posterior axillary fold. This was taken down through skin. The teres musculature was identified, as were the axillary and radial neurovascular bundles. The tendon was pulled back and scarred to the underside of thial portion of the triceps and this was freed up on the anterior, posterior, and inferior sides of this, with careful blunt and sharp dissection. After mobilization of the tendon and placement of a tag stitch it also became clear that the latissimus in addition had torn away from the humerus. This too was carefully mobilized with careful dissection. The landing zone slightly posterior to the bicipital groove was cleared away of the remnant soft tissue and decorticated with a ronguer carefully to induce a healthy bleeding response. The wound was then irrigated copiously. The two anchors were then passed separately through the full thickness of the tendons of both latissimus and teres major, with one limb of a locked Krackow running suture and the other a free tissue limb to add as a pulley stitch.”

Please recommend if we can report 2 units of 23410 or should we report only one unit of 23410 with modifier 22 (Increased procedural services) for the repair of the second tear.

Ohio subscriber

Answer: CPT^® code 23410 describes musculotendinous cuff (e.g., rotator cuff) repairs involving one or two tendons or major muscles of the rotator cuff. Teres minor, and not teres major, is a part of the rotator cuff. 

Since your surgeon is repairing the teres major and latissimus dorsi, you report two units of 24341 (Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary [excludes rotator cuff]).