1. Coding for Rotator Cuff Repair
Shelley C. Safian, PhD, RHIA
CCS-P, COC, CPC-I, ICD-10-CM/PCS Trainer
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2. Shoulder
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3. 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
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4. Safian Communications Services, Inc.

5. ICD-10-CM Diagnosis Coding
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6. First Question… Traumatic -Or- Non-traumatic
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7. Non-Traumatic Injury
Rotator cuff tear or rupture [Non- Traumatic]…M75.1--
AKA Rotator cuff syndrome
Supraspinatus syndrome
Supraspinatus tear or rupture [non-traumatic]
M Complete or M Incomplete
M75.—1 Right or M75.—2 Left
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8. Traumatic Injury
Injury of muscle(s) and tendon(s) of the rotator cuff of shoulder [Traumatic]…… S
S Strain *S Laceration *S46.09 Other
S Right or S Left
Sprain of the rotator cuff capsule [Traumatic]…S43.42-
S Right or S Left
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9. Don’t Forget… External Cause codes with a Traumatic Injury
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10. CPT Physician Services Coding
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11. 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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12. 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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13. 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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14. 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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15. Common Techniques Arthroscopy
Arthroscope + other instruments inserted via small incisions
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16. Arthroscopy
29827 Arthroscopy, shoulder, surgical; with rotator cuff repair
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acrominoplasty, with coracoacromial ligament (ie. arch) release, when performed
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17. Reconstruction
23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)
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18. ICD-10-PCS Inpatient Facility Services Coding
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19. 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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20. Any Questions??
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