Wiki removal of calcific tendinitis with repair of RTC


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I used a spinal needle and shaver and removed the calcium deposition, this did leave a hole in the supraspinatus tendon. I was also be repair the rotator cuff in side to side fashion with arthroscopic technique ...

Technically the Surgeron created the hole/tear in the RTC. Do I code for the repair or just the removal of calcific depostion?
Per NCCI Initiative, Incidental procedures include:
Treatment of iatrogenic (due to the action of the physician) complications caused and treated by the same physician during the same operative session. Additional procedures, not medially necessary prior to a service performed to treat a complication iatrogenically caused during that service are considered incidental to the primary procedure.
You can code the diagnosis for the RTC, but not the procedure.
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I don't think the resulting defect would be a complication of the surgery. Its the surgical approach to reach the calcific deposit and, like open surgery, whatever tissues the surgeon has to go through going in need to be repaired on the way out. I believe that is in NCCI guidelines as well. We only code the debridement not the RC repair.

Also, if you look at the lay description in the Coders' Desk Reference for the open procedure 23000 Removal of subdeltoid calcareous deposits it states:

The physician removes subdeltoid calcareous deposits by making a small incision over the deltoid muscle to expose the rotator tendons. The raised area over the calcium deposits is incised inline with the axis of the fibers and the calcareous deposits are removed. A large cavity is made in the tendon with a curette to remove all the damaged tissue. The opening is closed with side-to-side sutures. Once the tendon is repaired, the skin incision is closed and a soft dressing is applied.

The repair of the tendon is included in the procedure.
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