Your physician basically did a Revision Total Shoulder Procedure (23474), so that is where you start. During the course of the procedure, he "deliberately" performed an osteotomy of the humerus in order to allow removal of the humeral component, and avoid the possibility of the humerus fracturing during the removal of that component. Since the osteotomy, and its subsequent repair, were deliberate, it would have to be considered an integral part of the procedure. Therefore, charging separately for its repair would not be correct. At best you could add Modifier 22 (Increased Procedural Service) to the 23474 code.
As for the Greater Tuberosity Fracture, that was an Intra-operative Complication occurring during the procedure, i.e. the removal of the humeral component. This complication would require a diagnosis code to be included in the Operative Report/Postoperative Diagnoses. My research identifies two "reasonable" possibilities." The first, and what I would think the better, is M97.3 _ X _: Periprosthetic Fracture around a Shoulder Prosthesis (5th Character for laterality). This is an M code, but it is still a "Trauma" Code since it requires a 7th Character (A, D, or S only). There is nothing in the code's descriptor that excludes it from occurring intra-operatively, although Periprosthetic fractures usually are of the "traditional" traumatic origins/variety. The other possibility is M96.89: Other Intra-operative &/or Post-procedural Complication of the Musculoskeletal System, i.e. "intra-operative fracture of the Greater Tuberosity (S42.25 _ _) during the removal of a component during a revision arthroplasty procedure." Although both might work, I prefer the M97.3 code as it seems to be more "specific." Consequently, the CPT code for the repair of the tuberosity fracture (23630) could be submitted since it was an intra-operative complication requiring "active" treatment/repair. It would also require a Modifier, probably 51 for Multiple Procedures.
And last but not least, send the operative report as supportive documentation.
This is the best I can offer. I hope it helps.
Respectfully submitted, Alan Pechacek, M.D.
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