Wiki Reverse total and rotator cuff repair

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richelle25

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Hello
This issue has recently come up in our office. The provider does a reverse total shoulder and an open rotator cuff repair. Are you able to bill for both procedures, since NCCI edits do not show they are bundled or would the rotator cuff repair be included with the reverse total?
 
Are you certain you ran the NCCI edits correctly? Are you talking about 23472 & 23412? Does the payer follow Medicare?
Have you looked at the AAOS Global Service Data book?
What would your decision be on it?
 
amyjph said:
Are you certain you ran the NCCI edits correctly? Are you talking about 23472 & 23412? Does the payer follow Medicare?
Have you looked at the AAOS Global Service Data book?
What would your decision be on it?
Click to expand...

amyjph said:
Are you certain you ran the NCCI edits correctly? Are you talking about 23472 & 23412? Does the payer follow Medicare?
Have you looked at the AAOS Global Service Data book?
What would your decision be on it?
Click to expand...
Good Morning
Yes, the codes are 23472 and 23412. I am pretty sure I ran the edits correct, it shows a 1 in column modifier allowed. Also the AAOS global book states under 23472 that 23412 is a service not included in the global service package. With that information, I would be fine billing the two together, until, when you read the description for cpt code 23472, there is one line that is making me think 23412 is part of the procedure for 23472. It states" If large rotator cuff tears are found, they are repaired at this time." It does not state that this would be a separate procedure. Is there something I am missing or over looking?

Thank you
 
Did you read the NCCI manual Chapter 4, not just the P2P edit? And also Chapter 1? If this is a payer that follows Medicare, or Medicare.
19. With 3 exceptions (Chapter IV, Section E, Subsection 7) an NCCI PTP edit code pair consisting of 2 codes describing 2 shoulder procedures shall not be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder. This type of edit may be bypassed only if the 2 procedures are performed on contralateral shoulders.
L. More Extensive Procedure The CPT Professional often describes groups of similar codes differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic sites, the less complex service is included in the more complex service and is not separately reportable. Several examples of this principle follow: ...

I would also suggest checking CPT Assistant too, to see if there is guidance just to double check.
 
amyjph said:
Did you read the NCCI manual Chapter 4, not just the P2P edit? And also Chapter 1? If this is a payer that follows Medicare, or Medicare.
19. With 3 exceptions (Chapter IV, Section E, Subsection 7) an NCCI PTP edit code pair consisting of 2 codes describing 2 shoulder procedures shall not be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder. This type of edit may be bypassed only if the 2 procedures are performed on contralateral shoulders.
L. More Extensive Procedure The CPT Professional often describes groups of similar codes differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic sites, the less complex service is included in the more complex service and is not separately reportable. Several examples of this principle follow: ...

I would also suggest checking CPT Assistant too, to see if there is guidance just to double check.
Click to expand...
Thank you very much for you help.
 
richelle25 said:
Hello
This issue has recently come up in our office. The provider does a reverse total shoulder and an open rotator cuff repair. Are you able to bill for both procedures, since NCCI edits do not show they are bundled or would the rotator cuff repair be included with the reverse total?
Click to expand...
Hello, I code ortho on the inpt side and do not code rotator cuff repair, tenodesis , suture or transfer of nearby muscles in addition as they are included in the reverse total shoulder arthroplasty, if that helps.
 
hana17 said:
Hello, I code ortho on the inpt side and do not code rotator cuff repair, tenodesis , suture or transfer of nearby muscles in addition as they are included in the reverse total shoulder arthroplasty, if that helps.
Click to expand...
Thank you!
 
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