Wiki Incomplete Biceps Tenodesis

[adunlap23]

The doctor had planned and started an arthroscopic biceps tenodesis. However, during the surgery he noted "Unfortunately, with the severe tendon fraying, the tenodesis screw pushed right through the severe tendon fraying and would not hold. Both parts of the tenodesis screw were removed from the shoulder, and I decided a this point that a biceps tenodesis would not be possible and planned for a biceps tenotomy instead. I then amputated the proximal portion of the biceps tendon and allowed it to retract distally."
Do I code 29828-52 since he started but did not complete the biceps tenodesis? Or should I only code for the biceps tenotomy as part of a debridement code?

 

[CBLENNIE]

I think that if you are going to bill for the discontinued arthroscopic biceps tenodesis that modifier 52 is not appropriate because it is for reduced services, meaning that some portion of the procedure was completed and from the way I'm interpreting your post the surgeon did not complete any portion of the procedure, I feel like modifier 53-Discontinued Procedure is more appropriate in this situation. Encoder Pro defines each of these modifiers as follows:

52-Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.​

53-Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.​

You should then code for the actual procedure that the surgeon completed after discontinuing the arthroscopic biceps tenodesis.

 

[adunlap23]

I think that if you are going to bill for the discontinued arthroscopic biceps tenodesis that modifier 52 is not appropriate because it is for reduced services, meaning that some portion of the procedure was completed and from the way I'm interpreting your post the surgeon did not complete any portion of the procedure, I feel like modifier 53-Discontinued Procedure is more appropriate in this situation. Encoder Pro defines each of these modifiers as follows:

52-Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.​

53-Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.​

You should then code for the actual procedure that the surgeon completed after discontinuing the arthroscopic biceps tenodesis.

Thank you. I appreciate your help. Is there a specific ICD-10 code that needs to be reported with a discontinued procedure?

 

[CBLENNIE]

I don't think there is a requirement for an additional DX code for the discontinued procedure. However, if you wanted to include a code from chapter 21: factors influencing health status and contact with health services Z00-Z99, you might consider the following codes:

Z53.09-Procedure and treatment not carried out because of other contraindication.​

Z53.8-Procedure and treatment not carried out for other reasons.​

I think based on the reason for the provider discontinuing the procedure stated in your original post that Z53.8 is probably most appropriate. I don't know if you can definitively say the procedure was contraindicated which Z53.09 indicates, I think you would need the physician to actually state it was contraindicated for whatever reason in the report and your provider only states that the procedure was not carried out because "tenodesis screw pushed right through the severe tendon fraying and would not hold".

Whether the physician's statement meets the criteria for the procedure being contraindicated, I'm wouldn't be comfortable making that judgement. What I do know is that the procedure was not carried out because it would not be successful since the provider stated the tenodesis screw wouldn't hold based on the severe tendon fraying. So, if I were in your position and felt like I had to use an additional DX to indicate why the procedure was discontinued, I would go with Z53.8.

Since there isn't anything that requires the additional code to explain why the procedure was discontinued, I personally wouldn't bother with adding a Z code to the claim and linking it to the line for 29828-53.

I happen to work for a commercial insurance company and our provider administrative policy for using modifier 53 doesn't indicate that any additional DX is required to indicate what the procedure was discontinued. The policy only requires that the clinical information documented in the patient's record must support use of the modifier and include a statement indicating when the provider discontinued the procedure and the extenuating circumstances preventing the completion of the procedure.

 

[adunlap23]

I don't think there is a requirement for an additional DX code for the discontinued procedure. However, if you wanted to include a code from chapter 21: factors influencing health status and contact with health services Z00-Z99, you might consider the following codes:

Z53.09-Procedure and treatment not carried out because of other contraindication.​

Z53.8-Procedure and treatment not carried out for other reasons.​

I think based on the reason for the provider discontinuing the procedure stated in your original post that Z53.8 is probably most appropriate. I don't know if you can definitively say the procedure was contraindicated which Z53.09 indicates, I think you would need the physician to actually state it was contraindicated for whatever reason in the report and your provider only states that the procedure was not carried out because "tenodesis screw pushed right through the severe tendon fraying and would not hold".

Whether the physician's statement meets the criteria for the procedure being contraindicated, I'm wouldn't be comfortable making that judgement. What I do know is that the procedure was not carried out because it would not be successful since the provider stated the tenodesis screw wouldn't hold based on the severe tendon fraying. So, if I were in your position and felt like I had to use an additional DX to indicate why the procedure was discontinued, I would go with Z53.8.

Since there isn't anything that requires the additional code to explain why the procedure was discontinued, I personally wouldn't bother with adding a Z code to the claim and linking it to the line for 29828-53.

I happen to work for a commercial insurance company and our provider administrative policy for using modifier 53 doesn't indicate that any additional DX is required to indicate what the procedure was discontinued. The policy only requires that the clinical information documented in the patient's record must support use of the modifier and include a statement indicating when the provider discontinued the procedure and the extenuating circumstances preventing the completion of the procedure.

Thank you. This was very helpful!

 

[amyjph]

Sounds like it was more than just a tenodesis planned. Did they do a RCR and/or SAD and/or DCR at the same time? As for the failed tenodesis, you would code for what actually took place. You wouldn't append a 52 if the provider chose to switch to a different procedure during the case.
Whether or not you will code the tenotomy as part of a debridement depends on what else was done during the case. You would need to consider if any other procedures took place at the same time and, if debridement was done, were enough discrete structures to code a 29823.
You would have only coded 29828-53 if that was the only procedure planned, and he backed out after anesthesia and did not proceed with anything else due to risk to the patient, a cardiac problem for example.
A 29828-52 would not be appropriate here either in my view.

Examples:
If the plan going in was only a 29828 (pretty rare to do without any other shoulder joint work like rotator cuff but can happen), and the provider switched to a tenotomy due to the reason you stated above, it would most likely become 29822. However, that would only be if nothing else was done.

If the plan going in was something such as: 29827, 29826, 29824, 29828 yet the 29828 was changed to a tenotomy you would not code 29822 (one structure biceps tendon) because it would bundle with the other procedures. You would not report 29828-52 or 29828-53 at all (my opinion).