Wiki Arthroscopy Coding


Local Chapter Officer
Kyle, TX
Best answers
Can someone please tell me how to code....

DX 1. Large rotator cuff tear, rt shoulder
2. Glenoid Labral tear
3. Chronic ruptured long head biceps tendon. rt shoulder

1. Operative arthroscopy,subacromial decompression, and mini rotator cuff repair, right shoulder
2. Debridement, laberal tear, right shoulder

Description of procedure

A posterior arthroscopic portal was created followed by passage of Wissinger rod exiting lateral to the coracoid process. The joint is inspected. The glenohumeral articular surfaces appear normal. There is an abscense of the long head of the biceps tendon. There was a large retracted rotator cuff tear. There is degenerative tearing of the glenoid labrum which is debrided using a shaver. There is also synovitis which is debrided using a shaver.

Attention was turned to mini open rotaor cuff repair. An incision was made from the anterolateral edge of the acromion distally. The deltoid was split for approx 2.5 cm. There is an abundance of the bursal tissue which was resected. Minimal bony resection was required and the coracoacromial ligament was left intact. The decompression appears satisfactory.

There is a large retracted rotaor cuff tear. The tear was grasped and debrided sharply. A rongeur was then used to decorticate the greater tuberosity. Subsequently, repair is carried out using the Arthrex Speedbridge. Initially 2 anchors were placed in the greater tuberosity. The limbs of fiber tape were brought out from the articular surfaceto the bursal surface, taking greater than 1 cm bites. The repair was then tensioned. The fixation appears secure with the sutures. Subsequently the are divided and crisscrossed and 2 additional lateral row anchors are taken and tensioning and bringing the rotator cuff down onto the footprint. The sutures were divided the shoulder was carried through a range of motion the repair appears very secure.

Codes 23410 was paid while 29828 was denied stating records submitted do not support code.

I think the appropriate code is 29827? Can someone please tell me if I'm wrong?

29828 is a biceps tenodesis and it does not look like this is documented in the description you gave here. Also, 23410 should be 23412, as the op report also does not state there was an injury. 23410 is an acute code and 23412 is a chronic code. 29827 is an arthroscopic procedure, which was not code here. You can tell where the surgeon says "a mini open incision made." Also, depending on the insurance in this case, (not a government payer) 29822 can be coded here.