Wiki Bicep Tendon Muscle Transfers codes

[jdibble]

Good Afternoon!

I have a question about which would be the correct way to code for a bicep muscle transfer during a total shoulder arthroplasty. I have 2 different surgeons documenting the procedure and wanting to bill 23395 and we are not sure if that would be the correct code for each.

One surgeon documents his procedure as:
Biceps Tendon Muscle Transfer 23395
I then traced the long head of the biceps brachii from the pectoralis major through the rotator interval and released the biceps from its origin. The biceps tendon was diseased from the groove to its insertion on the supraglenoid tubercle. I then sutured the tendon into the pectoralis major tendon as a muscle transfer.

The other surgeon is documenting: The biceps tendon was tenotomized and tagged for later transfer to the anterior humerus, secured with a suture anchor, at the conclusion of the case.

The balance of each OP note describes the total shoulder surgery procedure.

They look like different procedures to me. Would these both be 23395 or different codes or would they each be a different CPT code all together? Any guidence would be helpful as if we need to change any of these codes we need to notify the surgeons with the reasoning why we their choice is not correct.

Thanks for all the help!

Jodi

 

[NRaizman]

This does not meet the definition of 23395. Not even close. It is a biceps tenodesis - 23430 - with a little window dressing.

There are some shoulder surgeons who are attempting to bill this as a tendon transfer to pad their billing, and the AAOS, KZA, and the coding representatives of ASES have confirmed that this is inappropriate at best and could easily be construed as fraudulent. There is some backstory to this, which I will not go into, but suffice it to say that you should caution your surgeons that this is not allowable.

 

[jdibble]

This does not meet the definition of 23395. Not even close. It is a biceps tenodesis - 23430 - with a little window dressing.

There are some shoulder surgeons who are attempting to bill this as a tendon transfer to pad their billing, and the AAOS, KZA, and the coding representatives of ASES have confirmed that this is inappropriate at best and could easily be construed as fraudulent. There is some backstory to this, which I will not go into, but suffice it to say that you should caution your surgeons that this is not allowable.

Thank you Dr. Raizman! So both procedures - bicep to pectoralis major and the bicep to humerus would be a tenodesis! This should be fun to explain to them! I appreciate your quick response!

I had listened to a Webinar (can't remember who held it) where they said 23430 could be billed with 23472 even though I find it bundled. Is there any truth to that?

 

[NRaizman]

There is truth. Since there's an NCCI Edit between 23472/23430, it cannot be coded with any CMS patient - that is why some clever ducks thought to use 23395 instead. That code was designed to cover a pectoralis major transfer for subscapularis loss and has a median intraservice time of 2.5 hours, completely out of line with a 90-second throwing of a few sutures between the pec tendon and the biceps (and this is 100% not a transfer, as you're suturing the biceps to the pec insertion, where the pull of the pec has zero effect on the biceps.).

In commercial payors, can bill 23430 with a -59 modifier.

 

[jdibble]

Excellent! That is so helpful! Thank you as always for your wealth of knowledge!

There is truth. Since there's an NCCI Edit between 23472/23430, it cannot be coded with any CMS patient - that is why some clever ducks thought to use 23395 instead. That code was designed to cover a pectoralis major transfer for subscapularis loss and has a median intraservice time of 2.5 hours, completely out of line with a 90-second throwing of a few sutures between the pec tendon and the biceps (and this is 100% not a transfer, as you're suturing the biceps to the pec insertion, where the pull of the pec has zero effect on the biceps.).

In commercial payors, can bill 23430 with a -59 modifier.