Orthopedic Coding Alert

Acute or chronic? A $60 difference is at stake. If youre not pinpointing where the orthopedic surgeon began a shoulder surgery, you could be overlooking separately reportable pre-repair procedures. Take a swing at the following real-life shoulder situation to see how your coding skills fare. Scenario: A 61-year-old general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem.The orthopedists physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear. The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and [...]