partial rotator cuff tear repair w/ subacromial decompression


Kings Beach, CA
Best answers
Requesting guidance on rc repair coding:
Would 23420 be correct procedure code based on following documentation?

1. Rotator cuff tear.
2. Acromioclavicular joint arthritis.
3. Impingement.

PROCEDURE: Subacromial decompression, debridement of the AC joint and
partial repair of the rotator cuff.

PROCEDURE: The patient was placed under anesthesia, prepped and draped the
left shoulder in standard fashion. We did an appropriate time-out, then made
a deltoid splitting incision, exposed the undersurface of the acromion. We
used the power saw to smooth out and resect the undersurface of the acromion
and power rasp to debride and smooth out the surface. We then explored the
rotator cuff. He had a massive rotator cuff tear and it was retracted
significantly, there were only a few fibers that we were able to stretch out
anteriorly, but it was not an adequate repair for this gentleman. We
debrided the undersurface of the acromion. We then irrigated vigorously, but
unfortunately I do not think he is going to get good function because there
were very few fibers that that we could . We then irrigated vigorously, let
the deltoid fall back in place, closed with Vicryl stitch, closed the skin
with 2-0 and staples. We applied a bulky dressing and a sling, awoken the
patient and transferred to the recovery room.

Any input would be greatly appreciated!
I'm not seeing that a "complete" RTC tear is documented there. I would verify that. He does not really state it as a diagnosis nor does he mention that there was a complete tear in the body of the note. He also does not state that the RTC tendon was actually repaired and what was used. It's pretty obvious that an anchor would have been placed and the tendon tied down. But nothing about actually repairing the tendon is documented. I would not bill a repair code with this documentation.