Shoulder experts-please help

AR2728

Expert
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312
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Perryville, MO
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I'm a little confused on how to properly code the following op report, assistance is greatly appreciated. Here's what I was thinking for CPTs : 29822 and 29999 for the tenotomy

PREOPERATIVE DIAGNOSIS:
1. Left shoulder impingement.
2. Left shoulder partial thickness rotator cuff tear.
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder impingement.
2. Left shoulder partial biceps tendon tear.
3. Left shoulder partial thickness rotator cuff tear.
PROCEDURE:
1. Left shoulder arthroscopic subacromial decompression.
2. Left shoulder arthroscopic biceps tenotomy.
3. Left shoulder arthroscopic bursectomy.

Diagnostic arthroscopy ensued. The patient did have fraying of the labrum anteriorly and
posteriorly. An anterior portal was made and the labrum was debrided. Patient also had grade II-III changes of his glenoid. At this point in time, the biceps was viewed and he had a partial tear. At this point in time, the tear was completed and a biceps tenotomy was performed. Once this was done, the arthroscope was placed in the subacromial space. There was abundant bursal tissue in the subacromial space. A lateral portal was made and a bursectomy was performed with a combination of shaver and the Vapr. At this point in time, the rotator cuff tendon was viewed and there was no tearing on the bursal surface. It should be noted there was tearing on the articular surface, however this was partial thickness and much less than 50% and therefore it was determined to leave the tear alone and only local debridement was performed. In the subacromial space, subacromial decompression was then performed using a cutting block technique. After this was done, the fluid was drained from the shoulder
 

nyyankees

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1,272
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Long Island/New York
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I'm a little confused on how to properly code the following op report, assistance is greatly appreciated. Here's what I was thinking for CPTs : 29822 and 29999 for the tenotomy

PREOPERATIVE DIAGNOSIS:
1. Left shoulder impingement.
2. Left shoulder partial thickness rotator cuff tear.
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder impingement.
2. Left shoulder partial biceps tendon tear.
3. Left shoulder partial thickness rotator cuff tear.
PROCEDURE:
1. Left shoulder arthroscopic subacromial decompression.
2. Left shoulder arthroscopic biceps tenotomy.
3. Left shoulder arthroscopic bursectomy.

Diagnostic arthroscopy ensued. The patient did have fraying of the labrum anteriorly and
posteriorly. An anterior portal was made and the labrum was debrided. Patient also had grade II-III changes of his glenoid. At this point in time, the biceps was viewed and he had a partial tear. At this point in time, the tear was completed and a biceps tenotomy was performed. Once this was done, the arthroscope was placed in the subacromial space. There was abundant bursal tissue in the subacromial space. A lateral portal was made and a bursectomy was performed with a combination of shaver and the Vapr. At this point in time, the rotator cuff tendon was viewed and there was no tearing on the bursal surface. It should be noted there was tearing on the articular surface, however this was partial thickness and much less than 50% and therefore it was determined to leave the tear alone and only local debridement was performed. In the subacromial space, subacromial decompression was then performed using a cutting block technique. After this was done, the fluid was drained from the shoulder
29823 for all - the biceps tenotomy 29999 will get bundled. we can also report biceps tenotomy with 29822 if there is a debridement After tenotomy...
 

OCD_coder

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Nashville AAPC Chapter
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I would agree with the 29823 as I just attended a Zupko seminar presented by Mary LeGrande and she was extremely helpful with improving our understanding of debridement.
Arthrosopic approach:
subacromial bursectomy = debridement
(when acromioplasty is not performed at the same setting)
biceps tenotomy = debridement
 
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