Outpatient Facility Coding Alert
Yes, You Can Report 2 Codes for Repairs of Both Shoulders
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Question: Our surgeon wants to report two units of 23410 for repairs done in same shoulder. There were tears of both the teres major and latissimus dorsi. Repair was done through a single incision for full thickness of tears of 90% of the tendon with a very small slip of the upper border of the tendon remaining attached.
Please recommend if we can report 2 units of 23410 or only one unit of 23410 with modifier 22 for the repair of the second tear.
Answer: CPT® code 23410 (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; acute) describes musculotendinous cuff (e.g., rotator cuff) repairs involving one or two tendons or major muscles of the rotator cuff. Teres minor, and not teres major, is a part of the rotator cuff.
Since your surgeon is repairing the teres major and latissimus dorsi, you report two units of 24341 (Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary [excludes rotator cuff]). You won’t need to append modifier 22 (Increased procedural services) since you can report two units of 24341.
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Yes, You Can Report 2 Codes for Repairs of Both Shoulders
Question: Our surgeon wants to report two units of 23410 for repairs done in same [...]