Orthopedic Coding Alert

Question: Our surgeon did the following procedures:

How do we report these procedures?

Ohio Subscriber

Answer: 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 will also report code +29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e. arch] release, when performed [List separately in addition to code for primary procedure]) for the subacromial decompression and acromioplasty.