Orthopedic Coding Alert

Question: A patient presents a postsurgery rotator cuff repair with a wound infection of the shoulder and an extension of the infection to the subacromial space. To correct it, the physician performed an open incision, irrigation and debridement of deltoid muscle subacromial space, arthroscopic inspection, lavage, debridement of subacromial space and glenohumeral joint. How should I code this and with which modifiers?

Texas Subscriber

 
Answer: Although CPT has a code in the arthroscopy category that describes surgery to address an infection of the knee joint, no such code exists for the shoulder. In this case, CPT directs us to report an unlisted-procedure code, which is 29909. You need to append modifier -78 (return to the operating room for a related procedure during the postoperative period). For the incision, irrigation and debridement of the deltoid region, report 10180 (incision and drainage, complex, postoperative wound infection) with modifiers -78 and -51 (multiple procedures).