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Orthopedic Coding Alert

Reader Question:

Report Rotator Cup Open Repair

Published on Wed Aug 10, 2011

Question: Which is the correct code(s) for the procedure described below: "Arthroscopy in the right shoulder showed some grade IV bone chondromalacia and grade IV exposed bone on the anterior glenoid. The remainder of the cartilage appeared fairly intact, but there was some softening and cracking grade II type chondromalacia on the remainder of the glenoid. The biceps tendon was intact, but was frayed. The labrum was intact. The rotator cuff had a large tear. Multiple strands of suture were identified. The anterior portal was made and this was done under direct visualization with spinal needle. Small incision was made and a trocar was inserted into the joint. Once inside, the cuff and tissues were probed. No loose masses were identified. The biceps was debrided and had approximately 90% of biceps still intact.

Considering the rotator cuff injury and foreign body removal, an open procedure was done. This was done through this former saber incision, carried long lateral aspect of the acromion anteriorly and then dissecting down to the deltoid and splitting the deltoid in anterolateral plane into the subacromial space. Small part of the anterior deltoid was removed off of the acromion. The findings were large loose calcific mass in the subacromial space. This was debrided and removed. Large rotator cuff tears with fairly degenerative tendon in the anterior supraspinatus and the tear of the infraspinatus tendon. There were multiple free strands of sutures identified and removed. These were Ticron type sutures. No anchors were identified after thorough probing intraarticular and around the subscapularis area and supraspinatus tendon. The tendon was then repaired to the tuberosity.

After freshening the tuberosity, removing of soft tissue and placing two anchors. It was an L-shape repair delivering the subscapularis and supraspinatus anteriorly to the first anchor and the posterior aspect closing with the second anchor and tuberosity followed by absorbable sutures of the longitudinal split. An acromioplasty was performed by taking the anterior-third of the acromion down using the oscillating saw and contouring with the rongeur and the saw. No impingement was identified afterwards. The wound was then flushed thoroughly, evacuated, and closed in layered fashion with the Vicryl sutures for deep and subcutaneous followed by Mastisol and Steri-Strips."

Florida Subscriber

Answer: You report 23412 (Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic). You can also report 23130 (Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release) unless the patient is Medicare primary. Be aware that Medicare CCI bundles 23130 into 23412. CCI and the American Academy of Orthopedic Surgeons (AAOS) agree that code 23000 (Removal of subdeltoid calcareous deposits, open) for open removal of calcareous deposits below the deltoid, if any, should not be reported in addition to 23412.

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