Wiki Denials for bundled codes 23412 and 29826

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bella2

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Hi,

I was wondering if anyone else is recieving denial for codes 23412 and 29826.
The carrier is Medicare, can we override the bundle with a 59 modifier.
The bundle dosen't make sense to me as one procedure is open and the other is arthroscopic ???

Thanks for any advice,

Bella
 
Bella, I add the modifier 59 when billing these 2 codes when documentation supports it. Here is an excerpt from Margie Vaught, who writes for AAOS:

Rotator cuff repair
Open rotator cuff repair is confusing because three codes can be used: 23410(Repair of musculotendinous cuff, acute), 23412 (Repair of musculotendinous cuff, chronic) and 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]).

There are no standardized definitions to distinguish acute from chronic. What often makes the difference is the size of the lesion (i.e., how many tendons are involved or whether the lesion is less than 1 cm, 1 cm to 3 cm, 3 cm to 5 cm or more than 5 cm), as well as the amount of retraction and scarring, not how long ago the tear occurred.

Code 23410 should be reserved for young patients who have an acute episode resulting in a torn rotator cuff and early repair. Code 23412 is more appropriately used for most of the rotator cuff tears that occur in older individuals who have sustained a tear over time, with or without a superimposed acute episode.

If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of code 23420. If fascia or synthetic material is required, code 23420 also is appropriate. If a tendon transfer was performed, code 23397-59 would be used in addition to code 23420.

Arthroscopic rotator cuff repair is code 29827 (Arthroscopy, shoulder, surgical, with rotator cuff repair). If arthroscopic subacromial decompression with or without acromioplasty and/or coraco-acromial ligament release also is performed, code 29826-51 is appropriate. If arthroscopic subacromial decompression is done, followed by an open or mini-open rotator cuff repair, the coding sequence should be 23410 or 23412 and 29826-59.

Hope this helps!

Ray CPC
 
Does this also mean that you can bill for the 29826 with the 23420? It looked a little gray in that area?
 
Bit Confused

I am bit confused now if we could code 23412 and 29826 for the same side shoulder as it clearly states that one is done opening the site and the other is done arthroscopically without opening the area.

Thus if you bill this ,Code 29826 becomes a component of Column 1 code 23412.-Bundled.

:confused::confused::confused:
 
Cuteyr said:
I am bit confused now if we could code 23412 and 29826 for the same side shoulder as it clearly states that one is done opening the site and the other is done arthroscopically without opening the area.

Thus if you bill this ,Code 29826 becomes a component of Column 1 code 23412.-Bundled.

:confused::confused::confused:
Click to expand...


If you have supporting documentation (please read Margies article above) then it can be unbundled using the 59 modifier.
 
29826/23412 NCCI guidelines

I had to research this subject sometime ago and things have changed from info given by the AAOS and others in 2004 regarding billing 23412 and 29826. In 2008 someone queried a representative from the NCCI and received this response from Niles Rosen, M.D. Medical Director of the NCCI and a CMS contractor. "Consequently for Medicare claims, it would NOT be appropriate to report the combination of codes 23412 and 29826 with modifier 59 unless these two procedures were performed at separate patient encounters or on contralateral shoulders at the same operative session." Now I know the AAOS may not feel this way, but there are many carriers who bill following Medicare (NCCI) guidelines and in my experience even with the -59 modifier added, 29826 will still be denied as bundled. Here's a link to the article: http://www.hip-inc.com/pdf/November 2008 Coding Tip of the Month.pdf

Denise Paige, CPC, COSC
Secretary, AAPC Long Beach Chapter
 
I had read that info as well. I posted what I had found because many are still quoting info from articles dating back to 2004.

Denise Paige, CPC, COSC
 
What if we look at it from this perspective rather than just the codes and laterality

Prior to 2012, CPT code 29826 was a standalone code and according to NCCI, was clearly bundled w/23412 unless it was a separate encounter or opposite shoulder. In 2012, CPT code 29826 changed from a standalone code to an add-on code. You can now report this only when your surgeon does another scope procedure. (Supercoder) (Note: if the parent scope procedure code does not have a CCI edit with 29826, and the 29826 is clearly documented as being related to that parent scope procedure [and not the OPEN Rotator Cuff Repair- 23412], then the CCI Edit does not apply to the 29826 because it is an add-on.)

So, from that I gathered that 29826 is an add-on to codes 29823/24 (arthroscopic synovectomy, debridement of biceps tendon, sub acromial decompression & clavicular resection). If 23412 does not appear to be a procedure that was converted from an arthroscopic procedure to an open procedure, and since there is no CCI edit to the parent codes of 29826; the add-on code would be payable too, since it’s stemming from the parent and not the rotator cuff repair.

Thoughts?
 
Did Supercoder allow you to use this methodology? I recall a trial pass where I had access for a day to use their services and it would let you know in an instant whether or not bundling was an issue as well as accepted diagnoses.

Peace
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