Orthopedic Coding Alert

Question: An MRI of the shoulder and pectoralis showed a bony fragment with a pectoralis tendon inserting on it. Follow-up films showed a bony fragment within about 2 cm of the shaft of the humerus and the orthopedist diagnosed a bony avulsion of the pectoralis major tendon. What's the best way to code for a shoulder repair of a pectoralis major with a bone fragment attached?

Maine Subscriber

Answer: Report 24341 (Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary [excludes rotator cuff]). This is your most accurate choice because it pertains to the upper arm where the pectoralis muscle is located.

Include 840.8 (Sprains and strains of shoulder and upper arm; other specified sites of shoulder and upper arm) as the diagnosis.