Wiki billed 29823, 29826 and 23120

[574coding]

Hello,
This is a URGENT request, we are on a limited time line to appeal with work comp IBR.
We billed code 29823-RT, with add on code 29826-RT and 23120-RT. CCI edit for code 29826 with 23120. We added modifier 59 to 29826. Payment received on 29823 and 23120. We need help with our fight with the insurance company for reimbursement on 29826. What CMS documents or other documents support the payment of code 29826 with 23120? Below is the op report for details.

The right shoulder/upper extremity was then sterilely prepped and draped. A standard posterior
arthroscopic portal site was made with the insertion of the arthroscope into the glenohumeral
joint. A standard anterior portal site was then made preserving neurovascular and tendinous
structures. I visualized all structures intraarticularly confirming no significant osteochondral
lesions and minimal chondromalacia of the glenohumeral joint. No loose bodies were present.
The biceps tendon was intact in the bicipital groove and the biceps-labral complex was intact.
There was partial labral tearing that was stable in the superior labrum and this was debrided back
to a stable labral rim as it was unreparable. The biceps tendon remained in the bicipital groove
through range of motion and probing under direct visualization. The rotator cuff had some
partial tearing less than 20% thickness of the rotator cuff at the insertion of the supraspinatus. A
radiofrequency wand was used to debride this to a stable cuff. I only had debrided the nonviable
torn fibers. Thorough irrigation and adequate hemostasis was then performed.
The arthroscope was then inserted into the subacromial space and a standard lateral portal site
was then made preserving neurovascular and tendinous structures. The subacromial space was
then addressed using the radiofrequency wand with an arthroscopic subacromial decompression
then performed. I used an acromioblaster bur to bur and flatten the undersurface of the acromion
so no further impinging structures remained in this region. The rotator cuff was intact to
inspection and probing on the bursal surface. Thorough irrigation and adequate hemostasis took
place.
A standard longitudinal incision was then made over the distal clavicle performing careful
hemostasis and dissection down to the distal clavicle incising the fascia and periosteum in line with the skin incision. A 1.5 cm of the distal clavicle was then excised with thorough irrigation
and closure using 3-0 Vicryl suture of the fascia and periosteum. The subcutaneous tissue was
then closed using 3-0 Vicryl suture and staples were used for skin wounds. Then, 20 mL of
0.5% Marcaine without epinephrine was injected about the incision sites for assistance in postop
anesthesia. Sterile Xeroform dressing and a sling were applied and the patient was taken stable
to recovery room. The patient remained stable throughout the procedure.

Thank you for your help

 

[OCD_coder]

If they were performed on the same shoulder joint, then the modifier 59 is not appropriate. The performance of the 29826 is included with a 23120 and a modifier 59 is only appropriate when performed on the opposite shoulder when done the same surgical session.

Rationale:
Because the acromion and clavicle meet and are part of the same joint, Medicare has bundled the 29826 to the 23120 because 75% of surgeons perform a decompression and acromioplasty when they perform a partial claviculectomy and applying a modifier 59 would not be correct when performed on the same shoulder. Eventhough, the CPT guidelines would indicate the 29823 would qualify as a base code to the 29826, they are bundled for a REASON.

BCBS follows McKesson CCI edits which at times are even more constrictive than MCR NCCI edits.