Wiki Insight: Superior Capsular Reconstruction & Rotator Cuff Repair

LaurenBrooke

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In patients with chronic rotator cuff disease, loss of the glenohumeral force couple, generated by the rotator cuff, results in superior subluxation of the humeral “head” and attenuation of tendon and joint capsule. Tissue degeneration also results in a high risk of failure when using more traditional repair techniques. In this setting, it may be necessary to augment the rotator cuff repair (complete or partial) with reconstruction of the superior joint capsule. In summation, restoration of the superior capsule creates a static restraint to superior migration and serves an internal splint to augment a rotator cuff repair. While the combination of these techniques for management of rotator cuff disease is a new
concept, the individual surgical procedures have established diagnostic and procedural codes. When the surgeon performs both procedures, we recommend 29827 for coding of rotator cuff repair and 29806 for capsular reconstruction.

In a SCR, the surgeon may use autograft or allograft tissue to reconstruct or repair deficient capsular tissues. As such, they should report 29806 when the technique is performed arthroscopically. If the surgeon also performs an arthroscopic repair, the residual rotator cuff tissue (complete or partial) 29827 should also be reported.

The surgeon should be sure to document restoration of the deficient superior capsular tissue and reduction of superior subluxation of the glenohumeral joint. The surgeon should also be sure to document the details of their repair of the rotator cuff tissue.

-In summary the above procedure, for myself, is currently coded as 29827, 29806-59 and when using dermal matrix for soft tissue reinforcement 17999 is applied. There is not a lot of documentation regarding the correct coding of the procedure described above; my question is how is it being coded within the Ortho community, and how are you handling denials for the portion 29806 represents? Am I not correct in splitting the superior capsular reconstruction from the rotator cuff repair, and is the biological implant for soft tissue reinforcement considered inclusive? If so, please direct me to supporting documentation.
 
July 2017 Healthcare Business Monthly has your answer

The superior capsule reconstruction is really misnamed and this causes much confusion. It is not a capsular procedure at all. The allograft really just holds the humerus in place.

This is not a repair of the tendon or capsule.

Reported with 29999.

Read the article.
 
The superior capsule reconstruction is really misnamed and this causes much confusion. It is not a capsular procedure at all. The allograft really just holds the humerus in place.

This is not a repair of the tendon or capsule.

Reported with 29999.

Read the article.

-I have read the article and do understand where it is coming from, but based on a March 2018 forum post you replied to you have stated:

"Unfortunately you don't give a lot of detail or information, so I am "assuming/guessing" that this is a shoulder surgery case. As such, the "superior capsule" of the shoulder joint is the Rotator Cuff[. To say that it was a "reconstruction" indicates that it was a severe/extensive/large/complex and probably chronic tear requiring a lot of hard work to repair it. Regardless of the severity and complexity of the tear and its repair, the code for Arthroscopic Rotator Cuff Repair is 29827 assuming it was all done arthroscopically and that was all that was done.The Code 29999: Unlisted arthroscopic procedure is essentially meaningless, and should only be used as a very last resort, and has to be "paired" with a code that most closely matches the procedure done in its complexity.

I hope this helps you some.

Respectfully submitted, Alan Pechacek, M.D."

I understand it is not your standard capsular procedure, but when done we are reinforcing the superior capsule- repairing the deficient capsular tissues. From your March 2018 response and this current thread, it seems there is some contradiction on how you choose to code this. Could you help me understand your thought process on this?

Also, I know I am not speaking on the RCR in detail in the original thread (the above description is what I am using for appeals when getting the 29806 paid separately), but typically when the SCR is done we are also repairing the RC which is why I have my current coding including both procedures. Just as a clarification.

Thank you
 
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