Outpatient Facility Coding Alert

Question: The surgeon performed rotator cuff surgery on a patient because of infection. . How would I code for irrigation, debridement, and removal of suture and anchor material in this region?

Arizona Subscriber

Answer: Whenever an arthrotomy or incision is made into the rotator cuff, you have two coding options, depending upon the joint involved. They are 23040 (Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body) and 23044 (Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body). Check the surgeon’s documentation to verify which area he treated so you can assign the correct code.

 Note: In cases where the surgeon documents the procedure as debridement, you’ll choose from the code range 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) -- +11047 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]). The appropriate option shall depend on the depth of debridement and the size of the wound.