Wiki Cpt 23410 and 23630

[Jocopoco53]

Can anyone send me a link from AAOS or anywhere why open Rotator Cuff repair be inclusive to a Orif Greater Tuberosity. I told the physcian it has a modifier indicator on it and its bundled , He is insisting i am wrong and one has nothing to do with the other. I advised the only way i can over ride is with a modifier 59. There was not a separate incision made. He feels they are both separate compartments

Please and thankyou
Grateful for this forum

 

[amyjph]

Look it up in the NCCI P2P edits, the reason is standards of medical surgical practice. Then, look up what that means in the manual. https://www.cms.gov/medicare/coding...iative-ncci-edits/medicare-ncci-policy-manual
If you have a copy of the AAOS Global Service Data, it is in there too. Rotator cuff repair is included.

 

[pamrasch@gmail.com]

Just so happens that I coded a case just like this today. I'll try to be clear and succint.

1. Greater tuberosity fractures are not always accompanied by a rotator cuff tear. The physician should provide a separate diagnosis regarding the tear. So you will have 2 ICD-10-CM codes for the injury.
2. CPT 23630 addresses the fracture care and 23410 addresses the open rotator cuff repair.
3. There is no NCCI edit for these two codes. I checked my 2021 manual copy of the NCCI lists and I use 3M encoder(current 2024 NCCI edits) and no edit was triggered. If it had been, I would have applied the -59 modifier. Since no edit was triggered, I applied the correct side modifier to both procedures.
4. On the HCFA 1500 form each diagnosis should point to the surgery that addressed that problem.
5. Possible caveats: I do facility coding in Louisiana. So depending on the insurance company and/or your medicare contractor, there may be differences.

 

[amyjph]

Respectfully disagree, the NCCI P2P edits can be found here: https://www.cms.gov/medicare/coding...s/medicare-ncci-procedure-procedure-ptp-edits
Some MACs also have a P2P edit checker where you can plug in the codes: https://www.cgsmedicare.com/medicare_dynamic/j15/ptpb/ptp/ptp.aspx
There most certainly is an NCCI edit for these codes and also for 23630 and 23412. Also we can't use a 2021 reference for 2024. However, even if you check 2021 there was an edit there too.
Not all payers may follow CMS, but most do. If it was WC I would consider reporting all CPT.
Facility is different or may be different compared to pro-fee.