lchiriac
Contributor
Hello everyone, I am looking for a second opinion for the next scenario. Based on documentation, would you bill the 29806-22 and 29807, or just the 29806-22?
Thank you!
"
Procedure In Detail: The patient was met in preoperative holding on the morning of 01/13/2026. Again all risks and benefits regarding the above indicated procedure were discussed with the patient. The patient stated that he understood and wished to proceed with surgery as recommended and previously discussed. After appropriate patient identification was completed, the right upper extremity was marked as correct operative site. The patient was then taken back to operative suite #6 at Intercommunity Hospital. Once in the operating room, the patient was safely transferred over to the OR table. At this time care was then turned over to the anesthesiologist who provided an interscalene regional nerve block to the right upper extremity followed by endotracheal intubation. Please refer to anesthesia notes for details. Once all lines and tubes were appropriately secured, the patient was then placed into the left lateral decubitus position. Time was taken to confirm that all bony prominences were well padded and that the axillary neurovascular structures of the left upper extremity were appropriately suspended. Bean bag was used to hold his position. At this time under general anesthesia the right glenohumeral joint was passively ranged and there appeared to be a 1+ instability with axial load and shift. SCDs were placed to bilateral lower extremities along with a Bair Hugger to the lower body and legs. The right upper extremity was then prepped and draped in normal sterile fashion. An operative time-out was completed. All parties agreed the right upper extremity is the correct operative site. The patient's right arm was then appropriately suspended with the Arthrex 3 point shoulder suspension system. At this time, the patient did receive 2 g of Ancef for antimicrobial prophylaxis per standard surgical protocol.
An 11 blade scalpel was then used to make a skin incision over the posterior lateral aspect of the acromion. Using a blunt trocar then atraumatically established a posterior standard viewing portal. Arthroscope was then introduced and diagnostic arthroscopy commenced. On diagnostic arthroscopy there was evidence of anterior glenoid fracture with medial displacement and attached anterior capsular tissue. The patient also did have a Buford complex. There was significant glenohumeral synovitis globally. The long head of the biceps tendon was intact. There did appear to be a SLAP lesion that extended into the posterior labrum all the way to the 7:30 position. At this time, a standard anterior working portal site was established using outside-in technique with the 18-gauge spinal needle through the rotator interval. Care was taken to make this portal incision as low as possible, but immediately superior to the superior border of subscapularis tendon. The portal site was then dilated in standard fashion and an 8.25 mm self-retaining cannula was then placed. A shaver was then used to debride the frayed labral edges. A tissue elevator was then used to identify the medialized anterior fracture fragment and to mobilize the fracture fragment. The shaver was then used to debride any fibrinous tissue at the fracture site and to establish good bleeding bone to encourage bone-to-bone healing once the anterior glenoid fracture fragment is reduced and stabilized. I then established an anterior superior portal site using outside-in technique with 18-gauge spinal needle through the most superior aspect of the rotator interval immediately off the anterior lateral aspect of the acromion. The arthroscope was then switched to the anterior superior portal site. At this time I then turned my attention to the posterior glenoid and Hill-Sachs lesion. An 8.25 self-retaining cannula was then placed into the posterior portal site. The shaver was then used followed by a ring curette to debride the fibrinous tissue within the Hill-Sachs lesion on the proximal humerus. Based on the anterior glenoid fracture and the dimensions of the Hill-Sachs lesion, I determined this lesion to be an engaging Hill-Sachs lesion also known as an off track lesion, therefore requiring an arthroscopic Remplissage. An 18-gauge spinal needle was then used to triangulate a separate arthroscopic portal site to complete the placement of the Remplissage anchors. An 11 blade scalpel was then used to make a skin incision over the posterior lateral aspect of the shoulder followed by placement of a 7 mm cannula within the subdeltoid space. Two 2.6 mm knotless FiberTak anchors were then placed in standard fashion through the cannula, taking care to preserve an appropriate tissue bridge for the Remplissage. Once the anchors were seated, they were clamped to be later converted and tightened at the end of the case. A probe was then used to probe the posterior labral tear at the 7:30 position and confirmed that it was a full-thickness tear requiring separate fixation. The posterior glenoid was then gently debrided for later posterior labral repair. An arthroscopic grasper was then used to appropriately confirm that the anterior fracture fragment along with the anterior capsular tissue was appropriately mobilized and was able to reduce to its anatomic position on the anterior glenoid. At this time, I then turned my attention to placing three 1.8 mm knotless FiberTak anchors along the fracture margin of the anterior glenoid. Once all anchors were replaced, I then used a Suture Lasso to shuttle the repair stitch around the fracture fragment and through the capsule labral tissue. Once all 3 repair sutures were shuttled, I then converted the anchors to the knotless mechanism. In a sequential fashion, I then tightened the sutures while holding the fracture fragment reduced in its anatomic position. Once I had the fracture fragment in its position all sutures were appropriately tightened and held the fracture fragment appropriately compressed against the anterior glenoid. Once all 3 sutures were final tightened, the sutures were then cut flush. A probe was used to probe the anterior glenoid repair which appeared stable with excellent compression. A bipolar wand was then used to debride the frayed anterior capsular tissue. Attention was then turned back to the posterior labral tear and standard steps to place a knotless 1.8 mm FiberTak anchor at the 7 o'clock position were completed followed by use of a Suture Lasso and passing the repair stitch around the torn posterior labrum. This was then shuttled through the knotless mechanism and tightened. Upon final tightening, there was excellent reduction and compression of the posterior labral tear. Suture was then cut. A probe was then used to probe the remainder aspects of the labrum which appeared to be intact. Attention was then turned to the originally placed Remplissage anchors and these sutures were then converted in a knotless horizontal mattress configuration. These sutures were then sequentially tightened and then cut leaving a short tail. Care was taken to ensure that the suture held the tissue only within the subdeltoid space. Final pictures of the arthroscopic repair were obtained confirming anatomic reduction of the anterior glenoid fracture fragment along with repair of the anterior capsular tissue and with repair of the posterior labral tear with associated Remplissage. On my final pictures the humeral head appeared to be appropriately centered on the glenoid without any incidence of instability. All cannulas and instruments were removed followed by removal of the arthroscope. Arthroscopic incision sites were then closed with 3-0 nylon. Dry sterile dressings were then placed. The patient was then placed into an arm sling. All drapes were removed. That concludes the operative procedure. There were no complications.
Final counts for sharps, sponges, and instruments were appropriate and all accounted for.
Care was then turned over to the anesthesiologist who extubated the patient without any complications. Please refer to her notes for details.
Indication For Modifier 22: Modifier 22 was indicated in addition to the CPT code 29806 due to the additional procedure of the Remplissage. Remplissage procedure added additional difficulty and time to the standard surgical case.
Thank you!
"
Procedure In Detail: The patient was met in preoperative holding on the morning of 01/13/2026. Again all risks and benefits regarding the above indicated procedure were discussed with the patient. The patient stated that he understood and wished to proceed with surgery as recommended and previously discussed. After appropriate patient identification was completed, the right upper extremity was marked as correct operative site. The patient was then taken back to operative suite #6 at Intercommunity Hospital. Once in the operating room, the patient was safely transferred over to the OR table. At this time care was then turned over to the anesthesiologist who provided an interscalene regional nerve block to the right upper extremity followed by endotracheal intubation. Please refer to anesthesia notes for details. Once all lines and tubes were appropriately secured, the patient was then placed into the left lateral decubitus position. Time was taken to confirm that all bony prominences were well padded and that the axillary neurovascular structures of the left upper extremity were appropriately suspended. Bean bag was used to hold his position. At this time under general anesthesia the right glenohumeral joint was passively ranged and there appeared to be a 1+ instability with axial load and shift. SCDs were placed to bilateral lower extremities along with a Bair Hugger to the lower body and legs. The right upper extremity was then prepped and draped in normal sterile fashion. An operative time-out was completed. All parties agreed the right upper extremity is the correct operative site. The patient's right arm was then appropriately suspended with the Arthrex 3 point shoulder suspension system. At this time, the patient did receive 2 g of Ancef for antimicrobial prophylaxis per standard surgical protocol.
An 11 blade scalpel was then used to make a skin incision over the posterior lateral aspect of the acromion. Using a blunt trocar then atraumatically established a posterior standard viewing portal. Arthroscope was then introduced and diagnostic arthroscopy commenced. On diagnostic arthroscopy there was evidence of anterior glenoid fracture with medial displacement and attached anterior capsular tissue. The patient also did have a Buford complex. There was significant glenohumeral synovitis globally. The long head of the biceps tendon was intact. There did appear to be a SLAP lesion that extended into the posterior labrum all the way to the 7:30 position. At this time, a standard anterior working portal site was established using outside-in technique with the 18-gauge spinal needle through the rotator interval. Care was taken to make this portal incision as low as possible, but immediately superior to the superior border of subscapularis tendon. The portal site was then dilated in standard fashion and an 8.25 mm self-retaining cannula was then placed. A shaver was then used to debride the frayed labral edges. A tissue elevator was then used to identify the medialized anterior fracture fragment and to mobilize the fracture fragment. The shaver was then used to debride any fibrinous tissue at the fracture site and to establish good bleeding bone to encourage bone-to-bone healing once the anterior glenoid fracture fragment is reduced and stabilized. I then established an anterior superior portal site using outside-in technique with 18-gauge spinal needle through the most superior aspect of the rotator interval immediately off the anterior lateral aspect of the acromion. The arthroscope was then switched to the anterior superior portal site. At this time I then turned my attention to the posterior glenoid and Hill-Sachs lesion. An 8.25 self-retaining cannula was then placed into the posterior portal site. The shaver was then used followed by a ring curette to debride the fibrinous tissue within the Hill-Sachs lesion on the proximal humerus. Based on the anterior glenoid fracture and the dimensions of the Hill-Sachs lesion, I determined this lesion to be an engaging Hill-Sachs lesion also known as an off track lesion, therefore requiring an arthroscopic Remplissage. An 18-gauge spinal needle was then used to triangulate a separate arthroscopic portal site to complete the placement of the Remplissage anchors. An 11 blade scalpel was then used to make a skin incision over the posterior lateral aspect of the shoulder followed by placement of a 7 mm cannula within the subdeltoid space. Two 2.6 mm knotless FiberTak anchors were then placed in standard fashion through the cannula, taking care to preserve an appropriate tissue bridge for the Remplissage. Once the anchors were seated, they were clamped to be later converted and tightened at the end of the case. A probe was then used to probe the posterior labral tear at the 7:30 position and confirmed that it was a full-thickness tear requiring separate fixation. The posterior glenoid was then gently debrided for later posterior labral repair. An arthroscopic grasper was then used to appropriately confirm that the anterior fracture fragment along with the anterior capsular tissue was appropriately mobilized and was able to reduce to its anatomic position on the anterior glenoid. At this time, I then turned my attention to placing three 1.8 mm knotless FiberTak anchors along the fracture margin of the anterior glenoid. Once all anchors were replaced, I then used a Suture Lasso to shuttle the repair stitch around the fracture fragment and through the capsule labral tissue. Once all 3 repair sutures were shuttled, I then converted the anchors to the knotless mechanism. In a sequential fashion, I then tightened the sutures while holding the fracture fragment reduced in its anatomic position. Once I had the fracture fragment in its position all sutures were appropriately tightened and held the fracture fragment appropriately compressed against the anterior glenoid. Once all 3 sutures were final tightened, the sutures were then cut flush. A probe was used to probe the anterior glenoid repair which appeared stable with excellent compression. A bipolar wand was then used to debride the frayed anterior capsular tissue. Attention was then turned back to the posterior labral tear and standard steps to place a knotless 1.8 mm FiberTak anchor at the 7 o'clock position were completed followed by use of a Suture Lasso and passing the repair stitch around the torn posterior labrum. This was then shuttled through the knotless mechanism and tightened. Upon final tightening, there was excellent reduction and compression of the posterior labral tear. Suture was then cut. A probe was then used to probe the remainder aspects of the labrum which appeared to be intact. Attention was then turned to the originally placed Remplissage anchors and these sutures were then converted in a knotless horizontal mattress configuration. These sutures were then sequentially tightened and then cut leaving a short tail. Care was taken to ensure that the suture held the tissue only within the subdeltoid space. Final pictures of the arthroscopic repair were obtained confirming anatomic reduction of the anterior glenoid fracture fragment along with repair of the anterior capsular tissue and with repair of the posterior labral tear with associated Remplissage. On my final pictures the humeral head appeared to be appropriately centered on the glenoid without any incidence of instability. All cannulas and instruments were removed followed by removal of the arthroscope. Arthroscopic incision sites were then closed with 3-0 nylon. Dry sterile dressings were then placed. The patient was then placed into an arm sling. All drapes were removed. That concludes the operative procedure. There were no complications.
Final counts for sharps, sponges, and instruments were appropriate and all accounted for.
Care was then turned over to the anesthesiologist who extubated the patient without any complications. Please refer to her notes for details.
Indication For Modifier 22: Modifier 22 was indicated in addition to the CPT code 29806 due to the additional procedure of the Remplissage. Remplissage procedure added additional difficulty and time to the standard surgical case.