Diane Posted Wed 31st of July, 2019 18:22:59 PM
Doctor did an open rotator cuff repair, it was shredded along the attachment of the humeral groove with a vertical split all the way to the musculature thus exposing the biceps tendon. Ther remainder of the rotator cuff was stuck to the undersurface of the acromion. An acromioplasty was done. Attempt was made to put in a suture anchor through the tendon but the tendon was so shredded a debridement of the shredded portion was done and discarded, then the biceps tendon was going to be used as a graft which closed the gap over the top of the humeral head . This was an acute injury. The rotator cuff tear code is 23410 but what code do I use for the graft which was the biceps tendon being used as the graft. Dr. dictated, " use of biceps tendon as graft reimforcement." I see no code either under grafts or in the shoulder section. Please advise. Hopefully I will not have to use unlisted. Would this be comsidered shoulder reconstruction 23420? Which I believe includes a graft. Also do I charge for debridement of the shredded rotator cuff? Thank you for your advise.
SuperCoder Answered Thu 01st of August, 2019 10:39:56 AM
Hi nbsp As per the above-mentioned report the surgeon performs a rotator cuff repair acromioplasty debridement of the shredded tendon and biceps tendon as graft reinforcement Generally rotator cuff repair for acute injury and acromioplasty are not performed in same session because its reasons that the acromioplasty was required for...