Open and arthroscopy procedures

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Modesto, CA; Central Valley Chapter
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Hello!

If a surgeon is doing arthroscopy debridement and subacromial decompression then open mini rotator cuff repair and mini open biceps tenodesis, would it be appropriate to append modifier 59.

In running CCI edits I see these are bundled but says a modifier is allowed, just trying to determine in what situations the modifier would be appropriate.

thanks
 

mbort

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ENGLEWOOD/DENVER
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Tina thats a tough one to answer because the documentation is what is going to be the determining factor as to whether or not you believe the 59 modifier is justified (my personal opinion)

Now the flip side---Based on strictly on CCI edits. No, you can not use the 59, you are in the same area, the subacromial decompression is most often done to visualize the RC therefore its bundled.
 

Diane Rozak

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Cpc-h, Cpc-gi

I have found that other payors other than Medicare will pay for the
the Arthroscopy Decompression and the Mini Open Rotator Cuff Repair.
I put the modifier on the Decompression. When the doctor plans on doing
the procedure this way it is appropriate to code them separately.
Just say that he had planned on doing and Arthroscopy Rotator Cuff Repair
then decides to change it to an open procedure then you can't code them
separate. Not all payors go by CCI edits.
 

mbort

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I do not feel that adding the 59 is appropriate because the doctor "planned" on doing a procedure. I feel that you must be very careful when using the 59 with this scenario (any scenario for that matter), making sure that the documentation supports the use of it.

If the doctor does the decompression for visualization, then I do not feel the 59 is justified.

If he does it because there is an acromial spur then I may consider the use of the 59.

Its all in the documentation.

I realize that not all carriers go by CCI edits, but unless I have another golden rule in my pocket to back up my coding ethics (ie AMA, AAOS, etc) then I go by the CCI edits.
 
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