jarmstrong20
New
I am going back and forth with Ortho on a case, and this one is a real puzzler. I have had a lively discussion with someone from their office, but we find ourselves at an impasse.
Scenario: pt had previous total shoulder that failed and presented for revision to reverse total shoulder. Doc removed and replaced the humeral component. For the glenoid component he left the original in place and then added new components. The office coded this as 23472 and my coding team coded this as 23474 (Inpatient-Only on an outpatient encounter...yay). After some research with HCPCS Coding Clinic we agree that the revision code is the best (thank goodness for that Coding Clinic!). However, the particulars of this case don't fit the CPT description precisely. They are thinking 23473 (since humeral was removed and replaced) but what about the glenoid?!? I want to use 23474, but it isn't a perfect fit. My logic is that since the glenoid was revised/augmented with the new component that would be considered revised, but I can't get past the CDR description that lists the removal and replacement as part of the revision. I want to avoid using unlisted if I can. Any help would be appreciated! Thank you!
Operative Technique:
The patient is brought to the operating room placed supine
on the operating table correctly identified and given general anesthesia.She
is given a scalene nerve block by the anesthesia department.After adequate
anesthesia is obtained she is placed in a beach chair position with hips knees
flexed and well-padded.She is brought to the table to allow full extension of
the glenohumeral joint and a humerus.After sterile prep and drape a skin
incision was made through her previous anterior deltopectoral skin incision.
His extended slightly proximally and distally for exposure purposes.Cephalic
vein was identified and was finally bleeding and was coagulated with 2 O Vicryl
sutures above and below the area of concern to ligate the vessel.Exposure of
the previous total shoulder arthroplasty humeral component was performed moving
the deltoid laterally and the pectoralis medially.The conjoined tendon was
identified and a right angle retractor was placed.She was found to have
failure of her subscapularis and partial failure of her supraspinatus as well
with some anterior superior escape of the humeral head.The humeral head
component was easily identified and with extension external rotation was
brought up into the wound.Ache pickle fork extractor was placed in the head
was removed.The glenoid was then exposed with an anterior tractor and
posterior tractor.Care was taken with the exposure with external rotation and
dissection of the capsule to identify the axillary nerve with a tug test and
protected with a curved retractor.Once the glenoid was exposed the labrum was
excised circumferentially and the base of the coracoid was marked after being
palpated.A drill holes placed in the glenoid using the Stryker Orthopedics
reunion system with 10 degree cephalic tilt.The glenoid was sized and a
curved Reamer was used to remove the articular cartilage down to inferior smile
or bleeding bone.The glenoid base plate 28 mm was then placed with a central
6.5 x 24 mm center screw with good solid fixation achieved.The superior and
inferior screw were then placed each 4.5 x 28 mm inferiorly and 24 mm
superiorly with good solid fixation.A 32+ 2 mm concentric glenosphere was
then impacted with good solid fixation.Attention was then turned to the
humerus.Because of the placement of the humeral stem being 2 superior the
stem was circumferentially dissected using flexible osteotomes and removed with
a broach extractor.Hand reaming was then performed and trial stems were
placed.The stem was downsized from 11 down to a size 9 which was then
impacted with good solid fixation and using the parallel to the floor technique
with approximately 20° of external rotation.Trial inserts and cups were then
looked at and a Stryker Orthopedics reunion humeral cup 30 2+4 and a humeral
insert 32+ 10 was chosen which gave excellent range of motion and excellent
stability.At the conclusion full motion was achieved with excellent stability
the ability to reach the top of the head the back of the head it was stable to
longitudinal traction and was stable to full extension with forward pressure so
as not to dislocate.The shoulder was copiously irrigated throughout the case
with pulse lavage fluid and Irrisept irrigation was used as well and irrigated
out with the pulse lavage.At the conclusion vancomycin powder was placed in
the deep in the wound and it was closed with 0 Vicryl to O Vicryl and skin
staples.Dry sterile dressings were applied patient was awakened in the
operative and transferred to the cuff room stable condition.Sponge needle
counts were correct.The PA assisted in all phase of the case including
positioning exposure hardware removal hardware placement and closure.
Antibiotics given preoperatively and a g of TXA was given at incision and
closure.
Scenario: pt had previous total shoulder that failed and presented for revision to reverse total shoulder. Doc removed and replaced the humeral component. For the glenoid component he left the original in place and then added new components. The office coded this as 23472 and my coding team coded this as 23474 (Inpatient-Only on an outpatient encounter...yay). After some research with HCPCS Coding Clinic we agree that the revision code is the best (thank goodness for that Coding Clinic!). However, the particulars of this case don't fit the CPT description precisely. They are thinking 23473 (since humeral was removed and replaced) but what about the glenoid?!? I want to use 23474, but it isn't a perfect fit. My logic is that since the glenoid was revised/augmented with the new component that would be considered revised, but I can't get past the CDR description that lists the removal and replacement as part of the revision. I want to avoid using unlisted if I can. Any help would be appreciated! Thank you!
Operative Technique:
The patient is brought to the operating room placed supine
on the operating table correctly identified and given general anesthesia.She
is given a scalene nerve block by the anesthesia department.After adequate
anesthesia is obtained she is placed in a beach chair position with hips knees
flexed and well-padded.She is brought to the table to allow full extension of
the glenohumeral joint and a humerus.After sterile prep and drape a skin
incision was made through her previous anterior deltopectoral skin incision.
His extended slightly proximally and distally for exposure purposes.Cephalic
vein was identified and was finally bleeding and was coagulated with 2 O Vicryl
sutures above and below the area of concern to ligate the vessel.Exposure of
the previous total shoulder arthroplasty humeral component was performed moving
the deltoid laterally and the pectoralis medially.The conjoined tendon was
identified and a right angle retractor was placed.She was found to have
failure of her subscapularis and partial failure of her supraspinatus as well
with some anterior superior escape of the humeral head.The humeral head
component was easily identified and with extension external rotation was
brought up into the wound.Ache pickle fork extractor was placed in the head
was removed.The glenoid was then exposed with an anterior tractor and
posterior tractor.Care was taken with the exposure with external rotation and
dissection of the capsule to identify the axillary nerve with a tug test and
protected with a curved retractor.Once the glenoid was exposed the labrum was
excised circumferentially and the base of the coracoid was marked after being
palpated.A drill holes placed in the glenoid using the Stryker Orthopedics
reunion system with 10 degree cephalic tilt.The glenoid was sized and a
curved Reamer was used to remove the articular cartilage down to inferior smile
or bleeding bone.The glenoid base plate 28 mm was then placed with a central
6.5 x 24 mm center screw with good solid fixation achieved.The superior and
inferior screw were then placed each 4.5 x 28 mm inferiorly and 24 mm
superiorly with good solid fixation.A 32+ 2 mm concentric glenosphere was
then impacted with good solid fixation.Attention was then turned to the
humerus.Because of the placement of the humeral stem being 2 superior the
stem was circumferentially dissected using flexible osteotomes and removed with
a broach extractor.Hand reaming was then performed and trial stems were
placed.The stem was downsized from 11 down to a size 9 which was then
impacted with good solid fixation and using the parallel to the floor technique
with approximately 20° of external rotation.Trial inserts and cups were then
looked at and a Stryker Orthopedics reunion humeral cup 30 2+4 and a humeral
insert 32+ 10 was chosen which gave excellent range of motion and excellent
stability.At the conclusion full motion was achieved with excellent stability
the ability to reach the top of the head the back of the head it was stable to
longitudinal traction and was stable to full extension with forward pressure so
as not to dislocate.The shoulder was copiously irrigated throughout the case
with pulse lavage fluid and Irrisept irrigation was used as well and irrigated
out with the pulse lavage.At the conclusion vancomycin powder was placed in
the deep in the wound and it was closed with 0 Vicryl to O Vicryl and skin
staples.Dry sterile dressings were applied patient was awakened in the
operative and transferred to the cuff room stable condition.Sponge needle
counts were correct.The PA assisted in all phase of the case including
positioning exposure hardware removal hardware placement and closure.
Antibiotics given preoperatively and a g of TXA was given at incision and
closure.
