Wiki Shoulder Question

[dsibley67]

Good morning! I need some help coding this op note, please! I see the 29828, and there is enough to bill 29823. What I am not sure about is 29826. I would greatly appreciate any help!

The patient was seen preoperatively, site was marked and
verified. Preoperative antibiotics were given. She was taken back to the OR. She was placed in a beach
chair position. All bony prominences were well padded. A posterior portal was established. We used an
inside-out technique to create an anterior portal. We then began to evaluate the joint. The cartilage
surfaces on the humeral head and glenoid were healthy in appearance. She has moderate fraying along
the lateral margin of rotator cuff which was debrided with a shaver. Otherwise the rotator cuff appeared
intact. The biceps had fraying in its insertion site. There was significant erythema along the anterior
capsule which was debrided with a shaver and cautery. The labrum had degenerative changes
circumferentially was debrided back to a smooth surface with cautery as well. The biceps tendon was
then tagged with a FiberWire sutures and released from its superior margin. The tagging stitch was then
incorporated with a 4.75 mm SwiveLock anchor to create our biceps tenodesis. The instruments were
then removed and placed in the subacromial space. The lateral portal was established. Extensive amount
of bursitis was cleared off of the undersurface of the acromion and superior aspect of the rotator cuff.
The rotator cuff appeared intact in the superior margin as well. The anterolateral margin of acromion had
several bone spurs which were debrided back to a smooth surface with a bur. At this point, the
instruments were withdrawn. The wounds were closed with nylon. She was placed in a sling and
tolerated the procedure well.

 

[kamalpal]

From the shared operative notes the only relatable statement but this alone is not sufficient to claim the cpt 29826.

"The instruments were then removed and placed in the subacromial space. The lateral portal was established. Extensive amount of bursitis was cleared off of the undersurface of the acromion and superior aspect of the rotator cuff.
The rotator cuff appeared intact in the superior margin as well. The anterolateral margin of acromion had several bone spurs which were debrided back to a smooth surface with a bur."

Hope it helps U.
Happing Coding

 

[dsibley67]

Do you think I have enough to bill 29823?

 

[NRaizman]

Do you think I have enough to bill 29823?

You have enough for EITHER 29823 or 29826 depending on your payor and whether they pay 29826. I agree that the documentation is weak to convincingly support 29826, though a decompression was clearly performed. The surgeon should be educated about this.

You can count cuff, labrum, bursa and bone spurs (4 structures), and you cannot count biceps because your primary procedure was the tenodesis.