scotta
New
Just wanting to know what CPT other coders would use for this procedure. The physician I code for is referring to it as a capsulotomy, but it's just not fitting the description 23020, which is the code he likes, b/c he views this as a less invasive capsular contracture release. His documentation is below. Thank you in advance!
Procedure note:
XXXXX is being seen today at the request of Dr.XXX for an ultrasound-guided steroid injection and capsulotomy for right adhesive capsulitis.
The risks, benefits and expected outcomes of the procedure were explained to the patient and verbal consent was obtained. An ultrasound was performed of the right shoulder to localize the posterior glenohumeral joint. The patient's skin was cleansed using chlorhexidine. Then under ultrasound guidance, the right posterior glenohumeral joint was injected with 40 mg Kenalog mixed with 5 mL of 1% lidocaine and 24 mL of normal saline. A large amount of capsular expansion was appreciated under the ultrasound. The patient did notice mild improvement with her pain following the procedure. A set of post injection instructions were given to the patient. The patient does have a scheduled followup with Dr. XXX.
Procedure note:
XXXXX is being seen today at the request of Dr.XXX for an ultrasound-guided steroid injection and capsulotomy for right adhesive capsulitis.
The risks, benefits and expected outcomes of the procedure were explained to the patient and verbal consent was obtained. An ultrasound was performed of the right shoulder to localize the posterior glenohumeral joint. The patient's skin was cleansed using chlorhexidine. Then under ultrasound guidance, the right posterior glenohumeral joint was injected with 40 mg Kenalog mixed with 5 mL of 1% lidocaine and 24 mL of normal saline. A large amount of capsular expansion was appreciated under the ultrasound. The patient did notice mild improvement with her pain following the procedure. A set of post injection instructions were given to the patient. The patient does have a scheduled followup with Dr. XXX.