Coding for Rotator Cuff Repair Shelley C. Safian, PhD, RHIA CCS-P, COC, CPC-I, ICD-10-CM/PCS Trainer Safian Communications Services, Inc.

Shoulder Safian Communications Services, Inc.

Definitions Rotator cuff Tear Rupture 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 Safian Communications Services, Inc.

Safian Communications Services, Inc.

ICD-10-CM Diagnosis Coding Safian Communications Services, Inc.

First Question… Traumatic -Or- Non-traumatic Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

Don’t Forget… External Cause codes with a Traumatic Injury Safian Communications Services, Inc.

CPT Physician Services Coding Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

Common Techniques Arthroscopy Arthroscope + other instruments inserted via small incisions Safian Communications Services, Inc.

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 Safian Communications Services, Inc.

Reconstruction 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Safian Communications Services, Inc.

ICD-10-PCS Inpatient Facility Services Coding Safian Communications Services, Inc.

Repair 0KQ50ZZ Repair, shoulder muscle, right, open approach 0KQ60ZZ Repair, shoulder muscle, left, open approach Fifth character = Approach 3 = Percutaneous 4 = Percutaneous Endoscopic Safian Communications Services, Inc.

Any Questions?? Safian Communications Services, Inc.