Help with shoulder surgery


Lexington, KY
Best answers
Please help with cpt codes for this procedure.

The diagnosis listed is: Left AC joint pain and left AC joint osteolysis.

OPERATIVE NOTE: The patient was seen and identified in the preoperative
holding area. Updated H&P was completed. The left upper extremity was
marked. Consent was obtained. Taken to the operating room. General
anesthesia. Placed in the modified beach chair position. All bony
prominence well padded. SCDs placed. IV antibiotics were given. Sterilely
prepped and draped the left shoulder. Made a transverse incision overlying
the clavicle into the acromion, slightly anterior centered over the AC
joint. Carefully used electrocautery and then identified the AC capsule,
which was protected. Made a U-type peelback of the capsule for later repair
from the clavicular side. Identified the anterior and posterior AC
ligaments, which were protected throughout the case. The patient did not
have any noted AC instability pre or post resection. Identified the AC
joint. He had a significant amount of scar tissue and calcified disk that
was slightly posterior. This was removed with other scar tissue. Proceeded
to make a 5 mm resection of the distal clavicle and rasped the acromial side
with minimal resection on the acromial side and then rasped the clavicle
side. I was careful using the saw to protect the AC ligaments and used a
single 2.9 mm PushLock anchor, double loaded with #1 Ethibond in the
superior portion of the clavicle centered A to P with excellent fixation and
then did a pants-over-vest repair of the capsule and then did an anterior
and posterior reinforcement with Ethibond and 0-Vicryl sutures confirming
excellent stability of the AC joint. Copious irrigation with Bacitracin and
saline. Deep closure with 0-Vicryl, 2-0 Vicryl, 3-0 Monocryl, and
Steri-Strips. The patient was placed in a neutral rotation sling and will
be protected. The patient was extubated without issue and taken to the
recovery area.

Thank you!!


True Blue
Salt Lake City, UT
Best answers
I think either 23120 or 23480. I have not seen this procedure before either. I would lean towards 23480. If someone has seen this before I would appreciate their thoughts as its only a matter of time before I see this too.
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