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open repair rotator cuff tear

  1. Default open repair rotator cuff tear
    Medical Coding Books
    Can someone explain the difference between codes 23410 and 23420. Regarding 23420, I was told it is for the repair of all three major muscles and for chronic tears. After reading the report, it syas 1 small tear, so I didin't know if I should ue the 23410, because i was told that is for 1 to 2 muscles/tendons

    OPERATIVE PROCEDURE: After satisfactory general anesthesia, the
    patient was positioned in the beach chair semi-Fowler position and the
    right shoulder was prepped and draped in usual fashion. The patient
    did receive preoperative antibiotics.
    The area for the skin incision was infiltrated with 0.5% Marcaine with
    epinephrine, and then a skin incision was made from the area on the
    top of the acromion and extending over the anterolateral aspect of the
    acromion for a total distance of about 2 inches and dissection made
    through the subcutaneous tissue. The deltoid was released from its
    attachments on the anterolateral aspect of the acromion, just to the
    AC joint. Minor bleeding controlled with electrocautery. Then, the
    AC ligament was released from its attachment on the acromion. The
    undersurface of the acromion was osteotomized in the Neer fashion,
    removing more bone anteriorly and laterally, and then the undersurface
    was smoothed with a rasp. The rotator cuff was then carefully
    inspected and there was one small 1 cm full-thickness tear that could
    easily be reapproximated just with #1 Ethibond sutures. There was no
    need for an anchor as the distal aspect of the tendon was still
    attached to the greater tuberosity.
    After it was felt to be a satisfactory repair of the defect, then the
    wound was irrigated thoroughly with normal saline. An On-Q single
    portal pump, 100 mL, was placed into proper position and primed, and
    then the deltoid was reapproximated using #1 Vicryl suture. The
    subcutaneous tissue was approximated with 0-Vicryl suture and the skin
    was approximated with a running subcuticular 2-0 nylon. A sterile
    bulky dressing was applied. The On-Q pump was finally assembled and
    then a sling was placed. The patient was then brought to the recovery
    room in satisfactory stable condition. She tolerated the procedure
    well and there were no complications. Blood loss was negligible, and
    there were no specimens, and sponge and needle counts were correct.

  2. Default
    23410 is for the repair. That is the procedure code you should use. The 23420 is for the complete shoulder.

  3. #3
    Default Differentiation
    23410 is the correct code.

    23412 is used for more chronic tears, or those that involve multiple tendons. If this is really your doc's report, I would recommend advising him to indicate what tendons are involved in the repair.

    23420 is used when additional procedures such as grafting are employed to accomplish the repair.

    I hope this helps!


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