Common Shoulder Conditions Require Comprehensive Anatomy
Get precise with anatomy to help code SLAP lesions and Bankart defects.
Ken Camilleis, CPC, CPC-I, CMRS, CCS-P
Coding shoulder-related diagnoses and procedures can be a challenge, but a working knowledge of the shoulder’s intricate ball-and-socket anatomy can help. Let’s explore in detail the anatomy and coding related to two common shoulder diagnoses: superior labrum anterior to posterior (SLAP) lesions and Bankart defects.
A SLAP on the Shoulder
A SLAP lesion forms in the uppermost portion of the glenoid socket at the insertion point of the long head of the biceps (referred to as the superior glenoid labrum). The tear extends from the front to the back part of the labrum. A SLAP tear is identified by a discontinuity across the biceps tendon, extending from the anterosuperior and anteroinferior areas of the shoulder to the area posterior to the tendon.
The etiology of a SLAP lesion can vary. This condition may be caused by a traumatic injury, repeated overexertion, or degeneration over time. Athletes who perform strenuous activities, such as throwing a baseball, subject their shoulders to extreme wear and tear, and are especially vulnerable to a SLAP lesion.
In addition to fraying of the superior glenoid labrum, other signs, symptoms, and manifestations that may indicate a SLAP tear include:
- Separation of the superior glenoid ligament and biceps brachii muscle from the glenoid rim
- Bucket handle tears of the superior glenohumeral ligament extending into the biceps tendon
- Instability of the shoulder due to separation of the biceps anchor
- Extension of tear anteriorly to below the medial glenohumeral ligament
- Excruciating pain in one of the shoulders often caused by strenuous exercise, or perhaps even by menial chores such as yard work
- Generalized loss of upper arm strength
- Impingement syndrome caused by overhead pressure on the shoulder
- Coexisting rotator cuff tear
- Shoulder area chondral damage
Clinical tests to detect a SLAP lesion include:
- Magnetic resonance imaging (MRI) (primarily used) or computed tomography (CT) scan
- Resisted-supination external rotation test
- Active-compression and compression-rotation tests
- Other tests such as pronated load, biceps load, dynamic labral shear, Speed’s test and SLAPprehension have been developed recently, and are used to diagnose SLAP lesions.
- MRIs are typically the most conclusive studies because they can show the entire 3-D extent of a labrum tear in a single view.
Coding for SLAP
The ICD-9-CM code to represent a SLAP lesion is 840.7 Superior glenoid labrum lesion. Degenerative or recurrent shoulder tears, including those of the SLAP genre, are reported with 718.31 Recurrent dislocation of joint, shoulder region. In ICD-10-CM, codes S43.43- Superior glenoid labrum lesion and M24.41- Recurrent dislocation, shoulder map to 840.7 and 718.31, respectively, but require additional digits to describe concepts such as laterality and the stage of healing.
SLAP lesions come in several varieties, graded I-VII:
Type I:Rough, frayed labrum, but with no detachment from the glenoid ligament
Type IIa:Tear anterior to midpoint of biceps
Type IIb:Tear posterior to midpoint of biceps
Type IIc:Superior labrum avulsed from bone
Type III:Bucket handle tear, biceps intact
Type IV:Bucket handle tear extending into biceps tendon
Type V:Combined SLAP/Bankart lesion
Type VI:Disruption of biceps tendon anchor with superior labral flap tear (requires tenodesis)
Type VII:Extension of SLAP tear anteriorly to the area inferior to the middle glenohumeral ligament
Types IIa-c subclassifications are the most common grades of SLAP defects.
Coding for repairs largely depends on the grade of the lesion. For example, types II and IV lesion repairs are reported most often using 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion (do not report 29807 for labrum tears that are not specifically SLAP tears). Type IV repairs also may require extensive debridement, reported with 29823 Arthroscopy, shoulder, surgical; debridement, extensive if the surgeon debrides both the anterior and posterior compartments of the glenohumeral joint.
Type I lesions are most often repaired by debridement (29823 or, less commonly, 29822 Arthroscopy, shoulder, surgical; debridement, limited). Type III lesions (bucket handle tears) may be repaired either by debridement (29823 or less commonly, 29822) or arthroscopy (29807).
The surgeon’s documentation should support the type of SLAP lesion being repaired. Review the surgical note for information about the type of SLAP lesion treated and whether the surgeon debrided both the anterior and posterior compartments of the glenohumeral joint.
Additional Procedures with SLAP Repair
Depending on the extent of shoulder damage, arthroscopic SLAP repair may include the following additional procedures:
If the debridement is extensive (especially during repair of a Type IV SLAP lesion), some payers may separately reimburse 29823. You may have to append modifier 59 Distinct procedural service to the debridement code, with medical necessity linkage (Block 24E of CMS-1500) to all diagnoses managed during the operative session.
Subacromial decompression with acromioplasty (+29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)) might link to conditions such as impingement syndrome (726.2 Other affections of shoulder region, not elsewhere classified) and subacromial bursitis (726.19 Other specified disorders of bursae and tendons in shoulder region).
Subacromial bursectomy (not separately reportable)
Biceps tenotomy: Check with your payer for details. This is often not separately reportable, but some payers may allow separate payment with 24310 Tenotomy, open, elbow to shoulder, each tendon, or possibly 23405 Tenotomy, shoulder area; single tendon or 23406 Tenotomy, shoulder area; multiple tendons through same incision.
Open subpectoral or arthroscopic biceps tenodesis (23430 Tenodesis of long tendon of biceps or 29828 Arthroscopy, shoulder, surgical; biceps tenodesis) may be performed in the case of damage extending into the biceps, medial instability, or following a previous, unsuccessful SLAP or Bankart repair.
Open or arthroscopic capsular contracture release (23020 Capsular contracture release (eg, Sever type procedure) or 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation). The latter applies to arthroscopic capsular release such as for adhesive capsulitis (726.0 Adhesive capsulitis of shoulder), which is not clear from the descriptor for 29825.
Open or arthroscopic capsulorrhaphy (23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block or 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy)
Total or partial rotator cuff repair (29827 Arthroscopy, shoulder, surgical; with rotator cuff repair)
Partial or total synovectomy (29820 Arthroscopy, shoulder, surgical; synovectomy, partial or 29821 Arthroscopy, shoulder, surgical; synovectomy complete)
Distal claviculectomy (29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure))
Diagnostic arthroscopy (not separately reportable)
Manipulation under general anesthesia (23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded))
These procedures may be reimbursed separately, depending on payer rules and/or the patient’s specific clinical situation.
Get Familiar with Bankart
Somewhat akin to a SLAP lesion, a Bankart tear or Bankart variant shoulder defect is a common cause of recurrent anterior glenohumeral conditions such as instability or dislocation. A Bankart tear is an avulsion of the periosteal sleeve off the anteroinferior labrum, and is a variant lesion typically associated with a dislocation code from Category 831 Dislocation of shoulder. Bankart tears may also code in ICD-9-CM to 718.31 or 718.21 Pathological dislocation of joint, shoulder region, which better describes an evolving, degenerative disease process. A Bankart lesion may also involve the coracohumeral ligament (840.2 Coracohumeral (ligament) sprain), the subscapularis (840.5 Subscapularis (muscle) sprain), or the entire rotator cuff capsule.
Arthroscopic repair of a Bankart lesion is reported with 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy, rather than 29807. The reason for this distinction is that the Bankart repair is a capsulorrhaphy, or suturing of the shoulder capsule, which is often documented as capsular plication. The clinical differences between repair of a Bankart lesion and that of a SLAP lesion are the surgical location and approach.
Shoulder Key Terms
Acromion – The lateral triangular projection of the scapular spine that forms the shoulder blade and articulates with the clavicle.
Anatomical neck – A constriction of the humerus just beneath the proximal shoulder joint surface, attaching to the capsule; superiorly, it’s a groove that separates the humeral head from the tubercles.
Bankart lesion/Bankart variant – An avulsion of the anterior capsule and glenoid labrum rim of the glenohumeral articulation, often caused by an anterior shoulder dislocation, resulting in recurrent instability.
Biceps brachii – The muscle of the upper arm that flexes the elbow and supinates the forearm.
Capsular plication – A procedure to bring the shoulder capsule closer to the bones by tightening the joint to prevent further dislocations or instability (often done with a Bankart repair).
Capsule – The enclosure around the shoulder joint.
Clavicle – The bone that articulates with the sternum and the acromion (collarbone).
Coracoid process – The sharp beak-like bone of the scapula that articulates with the acromion.
Coracoid process apex/summit – The short head of the biceps.
Deltoid – The nearly triangular-shaped muscle (resembling the Greek letter delta) that stretches from the clavicle to the humerus.
Glenoid fossa – The socket of the shoulder joint.
Glenohumeral junction – The shoulder joint (which is configured somewhat like a golf ball sitting on a tee).
Glenoid labrum – A ring of fibrous cartilage surrounding the glenoid fossa.
Glenoid process – The socket into which the humeral head fits.
Greater tuberosity – Also called the greater tubercle, a prominent process over the upper lateral end of the humerus, posterior to the lesser tuberosity, that serves as the insertion point for the supraspinatus, infraspinatus, and teres minor.
Hill-Sachs lesion – A disruption of the posterolateral humeral head resulting from anterior shoulder dislocation, affecting range of motion and shoulder function.
Humeral head – The “ball” of the shoulder that fits into the glenoid cup.
Infraspinatus – A muscle that originates from the infraspinous scapular fossa, with an insertion point at the posterior facet of the greater tuberosity of the humerus. Its tendon is instrumental in formation of the rotator cuff; its function is external rotation of the arm.
Labrum/Glenoid labrum – The ring of fibrocartilaginous tissue surrounding the glenoid cavity on the scapula.
Lesser tuberosity (lesser tubercle) – A projecting process on the anterosuperior end of the humerus, which serves as the insertion point for the subscapularis; smaller, but more prominent than the greater tuberosity.
Periosteal sleeve – The front end of the shoulder; an area especially subject to anteroinferior labral dislocations and avulsions of the Bankart family.
Remplissage – A process of smoothing out by filling a void with the rotator cuff tendon (known as a capsulotenodesis); often performed subsequent to a Bankart repair to treat recurrent dislocations caused by a Hill-Sachs lesion.
Rotator cuff – A family of muscles and tendons that function to stabilize the shoulder; its muscles are the infraspinatus, supraspinatus, subscapularis, and teres minor.
Scapula – The shoulder blade; a flat and nearly triangular-shaped bone, which articulates with the clavicle anteriorly.
Shoulder blade – See scapula.
Subacromial bursa (subdeltoid bursa) – The large bursa lying between the acromion and the coracoacromial ligament, above, and the insertion of the supraspinatus muscle, below.
Subscapularis – A large muscle that extends from the subscapular fossa, with an attachment point mostly at the lesser tuberosity and also at the humeral neck; one of the rotator cuff muscles; internally rotates the humerus.
Supraglenoid tuberosity – The long head of the biceps.
Supraspinatus – A small muscle that extends from the supraspinous scapular fossa, with an attachment point atop the greater tuberosity; one of the rotator cuff muscles; abducts the arm at the shoulder joint.
Surgical neck – A constriction below the tubercles of the greater and lesser tuberosities of the humerus; a common fracture site where such a break may compromise arm extension, flexion, and shoulder rotation.
Teres minor – A muscle that extends medially from the lateral edge of the scapula, with an attachment point at the inferior facet of the greater tuberosity. One of the rotator cuff muscles; externally rotates the arm.
Ken Camilleis, CPC, CPC-I, CMRS, CCS-P, is an educational consultant and PMCC instructor with Superbill Consulting Services, LLC, and a professional coder for Signature Healthcare, Massachusetts. Camilleis is the new member development officer of Massachusetts’ Quincy Bay Coders local chapter.