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Annette Posted Sun 29th of August, 2010 22:35:34 PM

Need some help with the following:

Doc wants to bill just 23130 & 23120......but Im thinking 23412, no 23130(bundled) and no 23120 bcuz no size of distal clavicle resection is mentioned

DX: right shoulder impingement syndrome (726.2), degenerative arthritis of AC (715.31)

Procedure: Subacromial decompression & bursctomy of right shoulder, lateral clavicle resection. & repair of partial thickness tear of the supraspinatus tendon

26 year old female with impingement syndrome of the right shoulder. The patient had failed to improve despite the use of antiinflammatories, corticosteriod injection, and extensive course of physical therapyl She did have an MRI which revealed evidence of impingement syndrome and synovitis of the AC joint. the patient after failing to show improvement with conservative management was indicated for surgery.

The proposed incision site over the anterior aspect of the acromion and clavicle was marked out and injected with 1% lidocaine with epinephrine. A linear incision was centered over this anterior and lateral aspect of the acromion and brought medially. A bovie electrocautery was used throughout the case for hemostasis. Upon obtaining the clavipectoral fascia, the plane was developed to create a mobile window and the Bovie electrocautery was used to perform deltoid on full thickness ablation of the deltoid tendon off of the acromion and the lateral clavicle. The anterior aspect of the acromion was noted to have a type II acromion and a Darrach retractor was inserted undersurface the coracoacromial ligament resection. The anterior aspect of the acromion was then resected with the oscillating saw and a darrach retractor was then further inserted under the acromion and the undersurface of the acromion was resected with the oscillating saw. Followed by use of the oscillating foot rasp to smooth the roughened edges down great care was taken to ascertain that the resection and dcompression then performed to the lateral most aspect of the acromion. The lateral clavicle was inspected and there was noted to be hypertrophic spurring along the inferior aspect and this was debrided with the oscillating foot rasp followed by resection of the lateral aspect of the clavicle with the oscillating saw followed by use of the oscillating foot rasp. At this point, a bursectomy was performed. There was notd to be over the supraspinatus tendon at the anterior aspect of the acromion and partial thickness tear of the superior surface of the supraspinatus tendon. This was not a full thickness tear. A 2-0 PDS suture was used in a figure of eight fashion to reapproximate this defect. The remainder of the cuff was inspected and found to be intact. The subscapularis and infraspinatus tendons were all noted to be intact and a glove finger was inserted and no further adhesions were appreciated.

thank you

Gina Answered Thu 02nd of September, 2010 10:52:42 AM

The size of the resection of the clavicle is not needed. I would code this 23410 and 23120. I do not see where he documents the tear is chronic.

SuperCoder Answered Fri 03rd of September, 2010 08:49:10 AM

This is the Orthopedic Coding Alert editor, and I forwarded this op note to her for review. Here's what she said:

"If the patient is Medicare primary, I would report 23412, 23120-51. However, if this is not a Medicare patient, I would report according to AMA/CPT guidelines as follows- 23412, 23130-51, 23120-51.

Heidi Stout"

Hope this helps!

Suzanne Leder, BA, M.Phil., CPC, COBGC
Editor, Orthopedic Coding Alert

Annette Posted Tue 07th of September, 2010 14:42:18 PM

I remember reading specifically CPT 23130 is bundled into 23412 per CCI edits and even though AAOS doesn't have 23130 as being bundled with 23412 there are still certain criteria that needs to be met.. for example " documentation of coplaning, or
changing a type II or type III acromion to type I....that is the
recommended documentation by AAOS.

Because so many carriers/payers are now bundling the acromioplasties
with rotator cuff repairs (RCR), it is getting harder to these paid. There are
basic 4 things that are part of an
acromioplasty. Notice that three of those things are also part of the

4 Parts of an Acromioplasty:

* 1 - Excision of the CA Ligament

- Part of a RCR

* 2 - Excision of bursa, deposits, etc

- Part of a RCR

* 3 - Cleaning of the AC Joint

- Part of a RCR

* 4 - Bony work on the Acromion

- NOT part of the RCR - can you support??

- so they are looking for physician documentation of that bony work,
not excision of osteophytes, CA release, etc. Key: You need to document
changing the shape of the acromion.

I have seen some great documentation examples, like: "I converted a type
III acromion to a
type I using ....."


"There was significant co-planing of the acromion due to sloping and XX
amount was removed"

Carriers are really looking for size, work, tools, etc. It is going to
come down to documentation of where the of the 'bony' work is being done
on the acromion to get reimbursed for 29826 or 23130.

AAOS states:

29826 Arthroscopy, shoulder, surgical; decompression of subacromial
space with partial ACROMIOPLASTY, with or without coracoacromial release

& According to CPT assistant and AAOS guidelines they both agree that size of distal clavicle resection does need to be documented at least 8mm-10mm to prove that this is just not removal of osteophytes/spurs

CPT Knowledge Base Vignette:

CPT 29824/23120

Following adequate exposure of the distal end of the clavicle, a motorized burr is introduced through the anterior portal and approximately 8-10 mm of the distal end of the clavicle is removed circumferentially. Intraoperative x-ray may be obtained to ensure distal clavicle has been adequately resected. The subacromial space and the area of the resected AC joint are injected with a mixture of Marcaine and morphine. The portal sites are closed with one or two stitches.


If part of the excision of the distal clavicle was through the open wound, then code 23120 is appropriate. The American Academy of Orthopedic Surgeons (AAOS) committee on CPT coding has agreed that excision of 1 cm or more of the distal clavicle is required before use of partial claviculectomy code (23120). Excision of a small osteophyte on the under-surface of the distal clavicle should not be considered a partial claviculectomy

ok so maybe because the op report states "type II acromion" maybe it's okay to bill 23130 but both AMA & AAOS states size of distal clavicle resection (23120) MUST be noted??? see above. Can you please forward this information to her & see what she thinks of it?

Annette Posted Wed 08th of September, 2010 08:49:24 AM

Susan Leder
If you please forward this to Heidi Stout with the above information I provided Thanks

SuperCoder Answered Thu 09th of September, 2010 10:52:52 AM

I've forwarded the info! I'll let you know what she says.

Suzanne Leder, BA, M.Phil., CPC, COBGC
Editor, Orthopedic Coding Alert

Annette Posted Thu 09th of September, 2010 23:14:12 PM

thanks alot!

Annette Posted Tue 14th of September, 2010 22:15:28 PM

Just following up... just making sure you haven't forgotten..
Thanks again

Annette Posted Mon 20th of September, 2010 04:58:58 AM

Susan Leder
I'm sorry I don't mean to rush you... but it's been over a week & just wanted to make sure if Heidi Stout will be responding to this... Thank you

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