Transcript Coding for Rotator Cuff Repair

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Coding for Rotator Cuff Repair
Shelley C. Safian, PhD, RHIA
CCS-P, COC, CPC-I, ICD-10-CM/PCS Trainer
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Shoulder
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Definitions
 Rotator cuff
 Structure of muscles and tendons that secure
the arm to the shoulder joint and enable
rotation
 Tear
 Strain from overuse or improper use
 Rupture
 Burst or torn open an organ or tissue
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ICD-10-CM
Diagnosis Coding
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First Question…
 Traumatic
 -Or Non-traumatic
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Non-Traumatic Injury
 Rotator cuff tear or rupture [Non-
Traumatic]…M75.1- AKA Rotator cuff syndrome
 Supraspinatus syndrome
 Supraspinatus tear or rupture [non-traumatic]
 M75.12- Complete or M75.11- Incomplete
 M75.—1 Right or M75.—2 Left
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Traumatic Injury
 Injury of muscle(s) and tendon(s) of the
rotator cuff of shoulder [Traumatic]…… S46.0- S46.01- Strain *S46.02- Laceration *S46.09 Other
 S46.0-1 Right or S46.0-2 Left
 Sprain of the rotator cuff capsule
[Traumatic]…S43.42 S43.421 Right or S43.422 Left
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Don’t Forget…
 External Cause codes
 with a Traumatic Injury
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CPT
Physician Services
Coding
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Repairing the Rotator Cuff
 Tendons are re-attached to the bone
 Dissolving suture anchors support re-
attachment
 Sutures tie the tendon back to the bone, using
the anchors for support
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Common Techniques
 Open Repair
 For large or more complex tears
 Mini-Open Repair
 Arthroscopy used to debride (remove
damaged tissue, bone spurs, etc.)
 Open part is used to repair rotator cuff
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Repair
 23410 Repair of ruptured musculotendinous
cuff (eg. rotator cuff) open; acute
 23412 Repair of ruptured musculotendinous
cuff (eg. rotator cuff) open; chronic
 NOTE: Open or mini-open rotator cuff repair,
use 23412
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Decompression
 23415 Coracoacromial ligament release, with
or without acrominoplasty
 Coracoacromial = related to the coracoid and
acromial processes
 Acromion = flat end of the spine of the scapula that
articulates with the clavicle and provide a point of
attachment for the deltoid and trapezius muscles
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Common Techniques
 Arthroscopy
 Arthroscope + other instruments inserted
via small incisions
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Arthroscopy
 29827 Arthroscopy, shoulder, surgical; with
rotator cuff repair
 +29826 Arthroscopy, shoulder, surgical;
decompression of subacromial space with
partial acrominoplasty, with coracoacromial
ligament (ie. arch) release, when performed
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Reconstruction
 23420 Reconstruction of complete shoulder
(rotator) cuff avulsion, chronic (includes
acromioplasty)
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ICD-10-PCS
Inpatient Facility
Services Coding
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Repair
 0KQ50ZZ Repair, shoulder muscle, right, open
approach
 0KQ60ZZ Repair, shoulder muscle, left, open
approach
Fifth character = Approach
 3 = Percutaneous
 4 = Percutaneous Endoscopic
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Any Questions??
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