Orthopedic Coding Alert

Question: Our surgeon documented a McLaughlin procedure for a reverse Hill-Sachs lesion. Which code should we report for this?


Michigan Subscriber

Answer: Surgeons perform McLaughlin procedures to treat posterior dislocating shoulders. During the operation, the surgeon performs a tendon transfer by moving the subscapularis tendon from its location on the lesser tuberosity into the reverse Hill-Sachs defect.

Sometimes the surgeon performs the McLaughlin as an isolated procedure from an anterior approach. More commonly, however, orthopedists perform the surgery with a posterior capsulorrhaphy through combined anterior (McLaughlin) and posterior (capsulorrhaphy) approaches.

If your surgeon performs the combined approach, you should report both 23395 (Muscle transfer, any type, shoulder or upper arm; single) and 23465 (Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block), with modifier -51 (Multiple procedures) appended.

If the surgeon documents an anterior approach only, you should simply report 23395.