Chappaqua, New York
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Hi all,

We have come across a surgeon trying to bill these CPT codes together for the same shoulder. There is a CCI edit but we cannot find more references and resources as to why these codes are inclusive of each other.

Please let me know.

Thank you!


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Without having the CCI edit to review and work from, I would surmise from your query that you physician's patient had both shoulder joint arthritis and a chronic rotator cuff tear, for which he did a Total Shoulder Arthroplasty and an Open Repair of the Chronic Cuff Tear. The "Powers That Be" have probably decided that the cuff repair would be considered an "integral" part of the Arthroplasty, and therefore would exclude it from being charged for separately as a "Multiple Procedure," particularly if the cuff tear was not very large and/or retracted, and thereby making it easy to repair at the time. The AAOS at one time produced a book titled: AAOS Complete Global Service Data, which defined what all was included in a procedure, such as a Total Shoulder Arthroplasty. But, my research indicates that the last version was in 2014. If you can get your hands on one of these, it might help to see what all is included in a TSR. However, the AAOS may have stopped producing it because of all the CCI Edits out there that do pretty much the same thing, but without much in the way of detail. To keep publishing that book, and keep up with all the changes from year to year, would be expensive and redundant. You are probably "stuck" with reviewing the CCI Edits pertaining to this "dilemma."
Unfortunately, I probably didn't help you as much as would have liked, but I tried.

Respectfully submitted, Alan Pechacek, M.D.