Wiki Mini-Open Rotator Cuff Repair with Arthroscopic Shoulder Procedures... Possible to Bill?

KStaten

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Hello Everyone,

I know this is a repeated question that frequently finds its way on this forum (apologies)... but, as with many coding scenarios, there seem to be mixed answers / solutions. Or, perhaps, I am misinterpreting it, which is also entirely possible. From what I have read, the collective answer seems to be that arthroscopic procedures cannot be billed during the same session on the same shoulder as with an open procedure. (?) However, I have also read many contradictions to this.

All suggestions are appreciated, as this is how we learn. :)

Thank you in advance,
Kim
 
General rule is that if you start a procedure arthroscopically, but complete the procedure open, you can only bill the open code, not both. That's probably what you have in mind.

But can you bill both open and arthroscopic procedures for shoulders? Yes. I have a doctor who does everything arthroscopic but then does the rotator cuff open?? I can't get him to change, but I am not a surgeon.
You can bill open and arthroscopic procedures, but they have to be different procedures. You can't bill the same procedure open and arthroscopically.
 
General rule is that if you start a procedure arthroscopically, but complete the procedure open, you can only bill the open code, not both. That's probably what you have in mind.

But can you bill both open and arthroscopic procedures for shoulders? Yes. I have a doctor who does everything arthroscopic but then does the rotator cuff open?? I can't get him to change, but I am not a surgeon.
You can bill open and arthroscopic procedures, but they have to be different procedures. You can't bill the same procedure open and arthroscopically
Thank you for clarifying. :) You are always helpful. That is how I had interpreted an article I had read from Karen Zupko, but I have heard/ read several other suggestions that have argued otherwise, claiming that arthroscopic procedures could not be billed on the same anatomical site if an open procedure was performed during the same session. On the flipside, one argument that I have heard/seen from time to time is billing +29826 with an open procedure, such as 23410 or 23412, by adding a -59. I think this perhaps stemmed from an older article prior to when 29826 became an add-on code (on January 1, 2012), and is still being referenced.

In instances like that, do you agree that (if documentation is justified) a modifier -22 is most appropriate?
Example: Limited debridement performed on a degenerative labral tear, followed by subacromial decompression with partial acromioplasty, AND a mini-open rotator cuff repair. (Same shoulder, same session.)

Separately, the codes would be 29822, +29826, and 23412. However, whereas 29822 bundles into 23412 and +29826 is an add-on code for parent codes 29806-29805, 29827 and 29828, in this scenario, would it be most appropriate to only bill 23412 with modifier -22 to reflect the additional work?

As Always, thank you!
 
Coding shoulder surgeries has changed significantly since I started surgeries in 2012. That's the same year that the AMA bundled 29877 with 29881. There is an older reference to using the -59 modifier on 29826 with open rotator cuff tears. But that is now outdated. Since then CMS has declared in their surgical policy manual that the shoulder is considered one anatomical unit, it's not! But that's their decision. Due to that decision you can no longer use -59 modifiers on shoulders. If the codes hit an edit, you can't report both. This was pointed out a few years ago in our HBM magazine. CMS also updated the surgical policy manual to state that 29822 can't be billed with any other code, must be billed on its own. Due to the policy changes made I don't agree that using modifier -22 is appropriate to capture 29822 & 29826 when open open RTC repair is performed. Don't get me wrong, I'm not saying that I agree with the changes that have occurred because I don't. The President of AAOS has met with CMS officials every year for several years trying to get their policies in line with reality. In 2017 CMS threw AAOS a bone by allowing 29823 under very limited circumstances. My personal opinion is that CMS understands that their policies don't reflect reality, but they don't change their policies knowing it would cost them more money in payments. But since private payers almost always follow CMS, we are stuck with policies that don't make sense simply because CMS is protecting their cash flow.
 
General rule is that if you start a procedure arthroscopically, but complete the procedure open, you can only bill the open code, not both. That's probably what you have in mind.

But can you bill both open and arthroscopic procedures for shoulders? Yes. I have a doctor who does everything arthroscopic but then does the rotator cuff open?? I can't get him to change, but I am not a surgeon.
You can bill open and arthroscopic procedures, but they have to be different procedures. You can't bill the same procedure open and arthroscopically.
When you say you have a doctor who does everything arthroscopic but does the rotator cuff open, do you code both the arthroscopic and open procedures? I'm finding conflicting information as well. My doctor did a shoulder arthroscopy with subacromial decompression, acromioplasty, Mumford distal clavicle resection, and mini-open rotator cuff repair. I coded 23412-RT, 29824-51-RT, and 29826-XU-RT. When I checked the global service data for 23412, per AAOS Code-X, 29824 and 29826 are NOT included. However, CCI shows 29826 as a column 2 code to 23412 but a modifier is allowed to differentiate between the services provided. Below is a snip of the global service data for 23412. What would be the proper way to code this? Should it be 23412 and 29824-51?
1609362894773.png
 
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