Wiki Mini-open RTC repair

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khopstein

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Is this enough documented to be billed for a mini-open rotator cuff repair:



“…lateral portal extended 1 cm proximal and distal and an anchor is placed at a good dead man's angle at the articular margin. With traction stitches placed through this rotator cuff tear, stitches are driven with horizontal mattress-type configuration through reasonably good quality tendon, securing the tendon down to the bone solidly with the traction stitches and the tails of those sutures. Then, they are placed through two 4.5 push-locks with 4 tails securely opposing a broader area of tendon at two different points with these push-lock anchors. With a solid repair achieved, then the field is copiously irrigated…”



I feel like this is enough for the procedure; however, BCBS is denying it for not enough documentation. Any suggestions?

Thanks,
Kristi, RMC, CPC
 
Is provider documenting the closure? I feel it is Mini-Open...are you billing open repair only?
 
Yes, he closed it with 2-0 vicryl and nylon. He also did an SAD, AC joint resection, and debridement of anterior & posterior labral tear. It was billed as followed:

23410 LT 840.4 (RTC tear)
29824 LT 715.91 (AC joint arthrosis)
29826 59 LT 726.2 (Impingement)
29822 59 LT 840.8 (Labral tear)

I know that there should be a 51 mod on the second one, but BCBS of Ms doesn't take this modifier.
 
I agree w/ the insurance company on this one at the most I'd give on this would be the mini-open RTC. 29827 vs 23410. Even that would really need clarification in the documentation.
 
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The other procedures are just not in the documentation. I would suggest a copy of Orthopaedics- Upper; Spine and Above. They have examples of these different procedures and it could give your surgeon a more clear idea of what needs to be documented.
 
The other procedures are well documented in the operative and insurance has paid them. The above insert is only the mini-open RTC repair portion of the operative report. They're just denying the mini-open RTC repair (23410) as not be enough documentation. Thanks for everyone's help. It is greatly appreciated.
 
for mini open rotator cuff repair, we always use 23412, not 23410. If you look at the notation under CPT 29827, this is the code we are directed to use. Do you think this might be part of the problem (using 23410 instead of 23412)? Just a suggestion....:)
 
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