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Unsuccessful shoulder reduction

  1. #1
    Default Unsuccessful shoulder reduction
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    Hello ortho coders!
    I code for family physicians so I don't typically use ortho codes on a daily basis. I'd like some advice for this scenario--my physician saw a patient in the ER with a shoulder dislocation. The patient has had several shoulder dislocations in the past.
    Documentation states: "L Shoulder has anterior dislocation of the humeral head that is palpable and visible, it is tender for pt to have it moved but does not act in pain at rest. I attempted to reduce her shoulder using bed sheet pulling opposite in the linear direction of her humerus first w/o sedation then again with 0.25mg of IV ativan which did not sedate her and I was unsuccessful."
    Can I use code 23650 even if the attempt was not successful? He did try the procedure twice with no success.
    Any advice would be greatly appreciated
    Carrie, BS, CPC

  2. #2
    Location
    Savannah Georgia
    Posts
    2
    Default Shoulder reduction
    I would use the modifier -52, reduced services, with the CPT code 23650 since the procedure was unsucessful.

    Leigh Lewis, CPC

  3. #3
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    yes you can, even though it was not successful, the valid attempt was there x2 therefore no 52 would be necessary either

    Mary, CPC, COSC

  4. #4
    Default Any other opinions?
    It looks like we have two different options--does any one else have advice on this scenario?
    Thanks!
    Carrie, BS, CPC

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default NOT 52 modifier
    The 52 modifier indicates that the procedure you planned to do is somewhat less than the code description. So I would NOT use a 52 modifier.

    A 53 modifier would be used to indicate that a procedure was interrupted or discontinued. But I'm not so sure that the procedure in this case was interrupted or discontinued.

    I'm leaning to agreement with Mary .. the entire procedure was performed (x2 no less), it just wasn't successful.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Default Thanks
    Quote Originally Posted by FTessaBartels View Post
    The 52 modifier indicates that the procedure you planned to do is somewhat less than the code description. So I would NOT use a 52 modifier.

    A 53 modifier would be used to indicate that a procedure was interrupted or discontinued. But I'm not so sure that the procedure in this case was interrupted or discontinued.

    I'm leaning to agreement with Mary .. the entire procedure was performed (x2 no less), it just wasn't successful.

    F Tessa Bartels, CPC, CEMC
    Thanks--I think I'm leaning more towards Mary also.
    Carrie, BS, CPC

  7. #7
    Default
    I am also a certified orthopedic coder and I agree with Mary. I would not put a modifier 52 because he did complete the service the joint just did not comply.

  8. #8
    Default
    Quote Originally Posted by beck627 View Post
    I am also a certified orthopedic coder and I agree with Mary. I would not put a modifier 52 because he did complete the service the joint just did not comply.
    Great--thanks for the confirmation!!
    Carrie, BS, CPC

  9. Default
    Mary is correct.

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