Wiki Proximal Humeral Fracture Dislocation

[cwilson3333]

Title of Procedure: Attempted Closed, Open Reduction and Internal Fixation Proximal Humeral Fracture Dislocation

Post op Diagnosis: Posterior fracture Dislocation, Left Shoulder

Looking at CPT 23615 for this surgical case.

Operative note extensive, so did not provide.

Questions concerning other charges that may be applicable.

Can I charge for the Attempted Reduction, which was unsuccessful.
ORIF was completed
Subscapularis was repaired with FiberWire Suture. Is this included in the ORIF.

I know this is brief, and but hopefully another ortho coder can answer.

Thanks

 

[fltbaroque]

23410 can be billed with 23615. However, 23605 is a column 2 code for 23615. I would not charge for the attempted reduction in the same session. If it was the day before, yes, adding a 58 modifier to the open surgery. But in the same session, no. I would treat it like any other surgery. If it starts out closed, but has to be opened, charge for the open, more extensive surgery.