Wiki Help on Total Shoulder Question Please

[sadieandbrian]

Wondering if I can please get some guidance on the following as I've never ran into this before and am unsure how to handle.

First...
We have a patient that went in for a reverse total shoulder arthroplasty (23474).
During surgery there was an intraoperative humeral shaft fracture.
The provider lists the total shoulder arthroplasty and ORIF of humeral shaft fracture.
Are these separately billable? Or is the fracture repair included since it was an intraoperative complication?

Second...
The same patient was taken back in for surgery the following day because of Interval loss of fracture reduction.
The provider lists Revision, ORIF, left humerus and Revision of humeral bearing component.

I'm really struggling with it and probably over-thinking it, so any guidance is much appreciated. Thank you!

 

[MI_CODER]

This is a challenging case.

If the provider performed a reverse total shoulder and accidentally fractured the patient's humerus then this would be considered an iatrogenic complication of the reverse total shoulder.

Chapter 1 (#14) of the 2018 NCCI Policy Manual states, "Treatment of complications of primary surgical procedures is separately reportable with some limitations. Treatment of complications is not separately reportable if it represents usual and necessary care in the OR during the procedure or if it occurs postoperatively and does not require return to the OR."

Chapters 5 and 6 (#3 and #10) state, "Treatment of an iatrogenic complication of surgery such as (splenic/intestinal laceration/perforation) is not a separately reportable service."

So, is the ORIF of the iatrogenic humeral shaft fracture billable? Even though it's not usual or part of the necessary care of the total shoulder procedure, I personally wouldn't bill for it. The NCCI policy makes it very clear that treatment of an iatrogenic complication of surgery is not a separately reportable service. I know a humeral fracture is not even in the same ball park as a splenic/intestinal laceration. However, I feel that these were just two examples that the NCCI policy gave yet the overall rule would still apply to any iatrogenic complication.

In regards to the return to the OR the following day, I do feel that this is billable with a modifier 78.

I'd really appreciate some of the other coder's opinions on this just to see where everyone else is at regarding iatrogenic complications.

 

[sadieandbrian]

Thank you for your reply, much appreciated!

So on the day 2 surgery with the modifier 78, would you bill for a revision to a total shoulder (23473)? I realize I haven't posted the complete op note...but since provider did revision of the humeral head component on day 2 along with again fixing the fracture, that was what I was thinking?

 

[meganszcz95@gmail.com]

I agree with Set_apart, that you would not bill for the fx repair on the first day b/c the surgery caused the fx (over simplified statement, i realize) and thus dr is responsible for fixing it.
For the second day, i wouldn't code a revision unless a prosthetic part was removed and reinserted. If you bill for the revision, I would still feel uncomfortable coding an orif here b/c again, he is addressing an issue that the first surgery caused. How are they addressing it? are they just using cables? or are they plating it? If just cables i wouldn't code an orif b/c that is something that is done during some arthroplasties when they fear the bone is compromised.
Megan CPC-A