23929 with 29827/29826?


Helena, MT
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Maybe this is a dumb question, but I am seriously drawing a blank on how I would code this. I have the initial arthroscopic repair of the subscap (29827) and then I see the 29826, but when it's switched to open...can I code that as an unlisted open code? Is there anything special I need to add for this dermal graft? I'm not sure if I can code the arthro and the open together? I'm really out of my element on this one, so any advice is greatly appreciated!!

The posterior portal was entered in the usual fashion.* Once in the shoulder, we could see the frayed biceps actually blocking visibility of the subscapularis.* The anterior portal was established, and it was at this time that we could appreciate that the supraspinatus and infraspinatus were retracted medially to the glenoid.* A lateral portal was established and bringing in a retractor, we attempted to move the rotator cuff, and it could only be brought a few millimeters lateral to the leading edge of the glenoid.* I felt this made it unrepairable.* The teres minor was in good shape.* The biceps was then looped and released to get it out of our way so that we could see the subscapularis.* The upper half of the subscapularis was delaminated and retracted.* Fortunately, the bulk of the fibers were present with this delamination, and we were able to make a bleeding bed in the subscapularis footprint and then with a FiberTape looped in the subscapularis, we were able to put a suture anchor into the bleeding bed and bring it into good position.* With external rotation to 60 degrees, there were no signs of gapping of that repair.*

Attention was then turned to this enormous hook on the anterior aspect of the clavicle.* It was much more prominent than was predicted by the MRI.* It was an ossification of the coracoacromial ligament.* The soft tissue was removed from the subacromial space as was the periosteum from the acromion, and then this hook was debrided with a burr taken back to a type 1 shape.* Then the distal clavicle was exposed.* It was found to be extremely erythematous and without any cartilage consistent with her history of arthrosis.* Using both lateral and anterior approach, a decompression was performed with the above space created and confirmed from both an anterior and posterior perspective.* Then the lateral bursectomy was completed to give better visualization.* The bleeding bed of the supraspinatus and infraspinatus footprint was then created.*

Then the remaining infraspinatus and supraspinatus were debulked from above the glenoid to gain access to the superior neck of the glenoid.* Using the Neviaser portal, two 3 mm suture anchors each with FiberWire were placed superiorly.* One of the two sutures from each of these two suture anchors were then pulled out laterally and the other two were saved in case there was a complication with those sutures.* Then the biceps was pulled out laterally as well, the shoulder was drained, instruments removed, and the mini-open incision was made.*

The incision was parallel to and lateral to the lateral border of the acromion.* Once down to the deltoid fascia, the subdermal fat was elevated with sharp and blunt dissection using scissors.* Then a longitudinal split was made in the lateral deltoid and retractors put in place and these sutures as mentioned above including the biceps pulled out through this opening.

The bleeding bed was excellent and had a little bit of modification done to smooth off the contours.* Then the thick dermal graft was brought in.* The appropriate side was marked.* The two sutures on the glenoid were passed so that we could figure-of-eight pass these sutures back over the glenoid.* After being passed, the central arms were tied, and then we were able to pulley the graft back into position.* It was palpated with a finger and could feel that it was in excellent position covering the superior aspect of the glenoid.* It was overtied in the usual fashion and was very secure in its position.

The graft was a little bit longer than we needed so it was trimmed at this time.* Then two 5.5 bioabsorbable suture anchors each with suture tape were placed in the medial edge of the bleeding bed.* Unfortunately, her bone was so soft that we did not even need dilators to pass the suture anchors in.* However, the purchase of the suture anchors was not terrible, which was somewhat surprising due to her poor bone quality.* The anterior-most suture anchor then had its FiberWire put through the biceps to tenodese it in position.* Then the suture tapes were passed through the graft and then divided.* One arm of each of these two suture tapes was passed through each of two FiberWires distal to the graft giving an excellent double-row fixation that was very stable with motion in the shoulder. The graft actually had covered over the superior edge of the teres minor, so side-to-side sewing was not performed.* It did not feel necessary at this time.* The wound was then thoroughly irrigated and attention turned to closure.

The deltoid raphe was closed with 0 Vicryl running locking suture.* The skin wounds were then all closed with 2-0 Vicryl subdermal interrupted sutures, Mastisol, and Steri-Strips.* Local anesthesia was administered for postoperative pain control, and then Betadine-soaked Adaptic, sterile dressing sponges, sterile ABD, and paper tape were applied.* She was transferred to the recovery room in stable condition.**


Munising, MI
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We are now doing these as well. We code all of the procedures, the 29827, 29826 (when done) & then use unlisted for the superior capsule reconstruction w/ dermal graft. I always support with a letter from the MD explaining this technique of the superior capsule reconstruction with a dermal graft which is compared to a TSA. Talk to your provider who is performing this procedure to give you a good write up explaining this procedure.