Documentation help

misnkm

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I have a denial for insufficient documentation for a Arthroscopic decompression subacromial space w/partial acromioplasty (29826- RT) it was billed with a 29824-51-RT and a 29827-RT that both paid correctly. Being new to ortho, I have lots to learn. (I have scheduled a boot camp)
This is how the Dr. documented the procedure:
Standard posterior portal created. The arthroscope inserted into the joint and examined systematically. Articular cartilage surfaces, labrum intact, biceps tendon absent, degenerative tear of the subscapularis with retraction. It was mobilized but not enough tendon tissue to reattach. Full thickness tear of the supraspinatus. Arthroscope redirected subacrominally. There was a reverse L-shaped tear of the supraspinatus tendon with fraying of the coracoacromial ligament in a type 2 acromion with degenerative changes at the AC joint. Rotator cuff was mobilized and repaired in a double row fashion with 2 medial 4.75 mm BioComposite Arthrex anchors that were bridged and secured laterally with two 5.5 mm SwiveLock anchors. An acrominoplasty was performed with the bur using the cutting block technique to covert it to a flat type 1 acromion. Distal clavicle resection performed removing 10 mm of distal clavicle and creating a 10 mm speace betgween the clavicle and acromion while preserving superior and posterior ligaments. Subacromial space irrigated. Portals were closed with nylon.

What could I advise my doc to add or reword to make the documentation clearly indicate his billed service?
Thanks so much.
 

Orthocoderpgu

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The subacromial decompression is not documented

In order to bill code 29826 you have to perform two procedures:

Subacromial decompression (resecting the subacromial bursa)

with

Acromioplasty

or

CA ligament release

The documentation supports the acromioplasty, but there is no mention of resecting the subacromial bursa.
 
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