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Help with attempted Rotator Cuff Repair

  1. Default Help with attempted Rotator Cuff Repair
    Medical Coding Books
    My Dr attempted to repair the Rotator Cuff but was unable to. Because of the time he spent trying to repair it he wants to add a 22 modifier on 29827. But bc it was never able to be repaired I was going to use 53 modifier. He DOES have documentation for a 22 modifier if he was actually able to repair the rotator cuff. Below is a cut out from the Op report. Should I use a 53 or should I use a 22? Trying to get some other opinions.

    1. Right shoulder arthroscopy, arthroscopic extensive
    debridement and synovectomy.
    2. Arthroscopic biceps tenotomy.
    3. Limited acromioplasty, but I did not release the
    coracoacromial ligament, and in fact, the acromioplasty was quite
    minimal for this reason, and then I performed an attempted
    rotator cuff repair, but unfortunately, the rotator cuff was so
    retracted even with various tricks to pull it back, it would not
    come back and therefore was not repairable. We spent actually
    most of the case time to repair the rotator cuff.

    After this was complete, I then made
    a lateral portal. I then went and tried to basically fix the
    rotator cuff. He did have a lot of spurring under the acromion.
    I did perform a minimal acromioplasty with a shaver, but I did
    not release the coracoacromial ligament, and really, the
    acromioplasty was fairly minimal just due to the fact that I did
    not want later go on and get instability anteriorly from having
    an incompetent coracoacromial arch with a massive rotator cuff
    tear. I then placed 3 traction stitches in the rotator cuff, and
    with the scope in the lateral portal and coming with the cannula
    in the anterior and posterior portal, I tried various things to
    release up to the coracoid. I tried to release the adhesions
    both on the rotator cuff and above the rotator cuff. I did
    coagulate any bleeders as I encountered them, but despite all the
    different tricks that we had to try to mobilize the tendon, it
    was so retracted back, I could only get it back to about 1 cm
    away from the greater tuberosity, so it was unfortunately not
    quite good enough to repair it. You could tell that it was
    actually probably there for quite some time. After I took
    probably good half an hour at least trying to repair it with
    various different releases and techniques we have to mobilize the
    tendon, unfortunately, we had to stop just due to the fact that
    it was quite evident that the rotator cuff was not able to get
    back to be repaired, but we spent quite a bit of time attempting
    to do the repair.

  2. #2
    I would go with covers what was done. I dont feel modifier 53 is appropiate. Hope this helps!

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