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Denials for bundled codes 23412 and 29826

  1. Default Denials for bundled codes 23412 and 29826
    Medical Coding Books
    Hi,

    I was wondering if anyone else is recieving denial for codes 23412 and 29826.
    The carrier is Medicare, can we override the bundle with a 59 modifier.
    The bundle dosen't make sense to me as one procedure is open and the other is arthroscopic ???

    Thanks for any advice,

    Bella

  2. #2
    Location
    San Antonio, Tx
    Posts
    73
    Default
    Bella, I add the modifier 59 when billing these 2 codes when documentation supports it. Here is an excerpt from Margie Vaught, who writes for AAOS:

    Rotator cuff repair
    Open rotator cuff repair is confusing because three codes can be used: 23410(Repair of musculotendinous cuff, acute), 23412 (Repair of musculotendinous cuff, chronic) and 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]).

    There are no standardized definitions to distinguish acute from chronic. What often makes the difference is the size of the lesion (i.e., how many tendons are involved or whether the lesion is less than 1 cm, 1 cm to 3 cm, 3 cm to 5 cm or more than 5 cm), as well as the amount of retraction and scarring, not how long ago the tear occurred.

    Code 23410 should be reserved for young patients who have an acute episode resulting in a torn rotator cuff and early repair. Code 23412 is more appropriately used for most of the rotator cuff tears that occur in older individuals who have sustained a tear over time, with or without a superimposed acute episode.

    If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of code 23420. If fascia or synthetic material is required, code 23420 also is appropriate. If a tendon transfer was performed, code 23397-59 would be used in addition to code 23420.

    Arthroscopic rotator cuff repair is code 29827 (Arthroscopy, shoulder, surgical, with rotator cuff repair). If arthroscopic subacromial decompression with or without acromioplasty and/or coraco-acromial ligament release also is performed, code 29826-51 is appropriate. If arthroscopic subacromial decompression is done, followed by an open or mini-open rotator cuff repair, the coding sequence should be 23410 or 23412 and 29826-59.

    Hope this helps!

    Ray CPC
    Ray Galvez CPC

  3. Smile
    Thanks for your help Ray, that information is perfect

    Cheers,
    Bella

  4. Default
    Does this also mean that you can bill for the 29826 with the 23420? It looked a little gray in that area?

  5. Default Bit Confused
    I am bit confused now if we could code 23412 and 29826 for the same side shoulder as it clearly states that one is done opening the site and the other is done arthroscopically without opening the area.

    Thus if you bill this ,Code 29826 becomes a component of Column 1 code 23412.-Bundled.


  6. #6
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Quote Originally Posted by Susan0131 View Post
    Does this also mean that you can bill for the 29826 with the 23420? It looked a little gray in that area?
    No because 23420 states in the CPT descriptor that it includes the acromioplasty.
    Mary, CPC, CANPC, COSC

  7. #7
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Quote Originally Posted by Cuteyr View Post
    I am bit confused now if we could code 23412 and 29826 for the same side shoulder as it clearly states that one is done opening the site and the other is done arthroscopically without opening the area.

    Thus if you bill this ,Code 29826 becomes a component of Column 1 code 23412.-Bundled.


    If you have supporting documentation (please read Margies article above) then it can be unbundled using the 59 modifier.
    Mary, CPC, CANPC, COSC

  8. #8
    Location
    Long Beach, CA
    Posts
    33
    Default 29826/23412 NCCI guidelines
    I had to research this subject sometime ago and things have changed from info given by the AAOS and others in 2004 regarding billing 23412 and 29826. In 2008 someone queried a representative from the NCCI and received this response from Niles Rosen, M.D. Medical Director of the NCCI and a CMS contractor. "Consequently for Medicare claims, it would NOT be appropriate to report the combination of codes 23412 and 29826 with modifier 59 unless these two procedures were performed at separate patient encounters or on contralateral shoulders at the same operative session." Now I know the AAOS may not feel this way, but there are many carriers who bill following Medicare (NCCI) guidelines and in my experience even with the -59 modifier added, 29826 will still be denied as bundled. Here's a link to the article: http://www.hip-inc.com/pdf/November%...he%20Month.pdf

    Denise Paige, CPC, COSC
    Secretary, AAPC Long Beach Chapter

  9. Default Beckers Review/ AAOS articles (2012)

  10. #10
    Location
    Long Beach, CA
    Posts
    33
    Default
    I had read that info as well. I posted what I had found because many are still quoting info from articles dating back to 2004.

    Denise Paige, CPC, COSC

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