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Orthopedic Coding Alert

Reader Question:

Discretely Report Each Step in Shoulder Surgery

Question: Our surgeon did the following procedures:Left shoulder arthroscopy with subacromial decompressionAcromioplastyBiceps tenotomyRotator cuff repair, mini openDistal clavicle excision, openHow do we report these procedures?Ohio SubscriberAnswer: It isn't clear if the biceps tenotomy and the acromioplasty were arthroscopic or open. You report 23412 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic) for the repair of the rotator cuff. Since your surgeon is doing a biceps tenotomy, you report 23440 (Resection or transplantation of long tendon of biceps). Also, your surgeon is doing an excision of the distal clavicle, this may be reported a partial excision of clavicle with code 23120 (Claviculectomy; partial). You append modifier 59 (Distinct procedural service...) to codes 23440 and 23120 to indicate that these were separate procedures. For shoulder arthroscopy, you will report 29822 (Arthroscopy, shoulder, surgical; debridement, limited) or 29823 (Arthroscopy, shoulder, surgical; debridement, extensive) depending upon the extent of the debridement. You [...]

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