shoulder scope

drussotti

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Need opinions. Now working for new Ortho practice & their dictation is different than I am used to seeing. I would really appreciate if I get another opinion re: codes on this op report. I might just be reading it over to many times and doubting myself. But as I said, I am so used to the transcription from the previous practice I was at. Thanks for your help

After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The circumferential labrum tear was debrided with a sucker shaver and the arthrocare wand. Capsulotomy was performed with sucker shaver and electrocautery device. Attention was paid to the rotator interval which is open from the superior glenohumeral ligament to the subscapularis tendon. Capsule overlying the subscapularis tendon was then debrided and removed. Attention was then paid to the posterior capsule, extending from the 11 o'clock position to the 7 o'clock position the capsule was debrided away. At the inferior aspect of the debridement, the axillary nerve was identified. 7:00 portal was placed into the shoulder and debridement of the osteophyte was performed with sucker shaver, 4 oh bone cutter, and bur. C-arm was used to confirm location on the inferior humeral head. Neural lysis was performed to free of the nerve. *
Instruments were removed from the shoulder and the trocar was redirected into the subacromial space. The subacromial space an 18-gauge needle was placed to localize the lateral portal site and was directly visualized. An 11 blade was then used established the portal site. This was followed by insertion of the 4.5mm cannula and ArthroCare wand. Both ArthroCare wand and sucker shaver were used to debride the subacromial bursa. The coracoacromial ligament was left intact. No bursal sided tears were identified in the subacromial space. After completion of the subacromial bursectomy instruments were removed from the shoulder.**
Open subpectoral biceps tenodesis was performed. The patient's arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.*
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.
 
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Hello drussotti,

I reviewed the documentation you provided and am thinking....

*29806
*29823 (edits w/ 29806 thinking not wouldn't bill?)
*29826
*23430
 

StuC2018

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New to ortho as of 2/4/2019

Anyone know accepted criteria for 29806 and 29823 being paid together ever or never?
Thank you!
 

KG123

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Can 29826, 29827, and 29823 be billed together? I am fairly new coding ortho and have just recently stated to receive denials for 29823.
Thanks
 
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Can 29826, 29827, and 29823 be billed together? I am fairly new coding ortho and have just recently stated to receive denials for 29823.
Thanks
29827, 29823, and 29826 can be billed together as long as the debridement was extensive and was not associated with the rotator cuff repair (debridement is included in 29827).
If you meet the criteria to bill 29823, append a 59 modifier to the code.
In my experience, you are encountering denials because they are trying to bundle 29823 with 29827.
 

Vmyers831

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29827, 29823, and 29826 can be billed together as long as the debridement was extensive and was not associated with the rotator cuff repair (debridement is included in 29827).
If you meet the criteria to bill 29823, append a 59 modifier to the code.
In my experience, you are encountering denials because they are trying to bundle 29823 with 29827.
i thought there was policy/ edit several years ago not allowing a 59 modifier appended to certain shoulder scope codes, unless it was a separate shoulder. Has this changed?
 

Orthocoderpgu

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Medicare (CMS) does not allow -59 modifiers to be used with the shoulder since they incorrectly consider it one anatomical structure. Per the 2017 CMS NCCI Surgical Policy Manual page seven, section seven, code 29823 may be billed but must be paired with 29824, 29827 or 29828. And 29822 can only be billed if it is the only code being billed.
 
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New to ortho as of 2/4/2019

Anyone know accepted criteria for 29806 and 29823 being paid together ever or never?
Thank you!
They cannot be billed together! They are bundled. However, I do not see where the Labrum was repaired, it appears to me it was debrided. I would code 29823 for Ext Debride and 23430 for Open Tenodesis. I do not see where 29826 was done, Scope partial acromioplasty and I do not see 29827, Scope RCR either.
 
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Need opinions. Now working for new Ortho practice & their dictation is different than I am used to seeing. I would really appreciate if I get another opinion re: codes on this op report. I might just be reading it over to many times and doubting myself. But as I said, I am so used to the transcription from the previous practice I was at. Thanks for your help

After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The circumferential labrum tear was debrided with a sucker shaver and the arthrocare wand. Capsulotomy was performed with sucker shaver and electrocautery device. Attention was paid to the rotator interval which is open from the superior glenohumeral ligament to the subscapularis tendon. Capsule overlying the subscapularis tendon was then debrided and removed. Attention was then paid to the posterior capsule, extending from the 11 o'clock position to the 7 o'clock position the capsule was debrided away. At the inferior aspect of the debridement, the axillary nerve was identified. 7:00 portal was placed into the shoulder and debridement of the osteophyte was performed with sucker shaver, 4 oh bone cutter, and bur. C-arm was used to confirm location on the inferior humeral head. Neural lysis was performed to free of the nerve. *
Instruments were removed from the shoulder and the trocar was redirected into the subacromial space. The subacromial space an 18-gauge needle was placed to localize the lateral portal site and was directly visualized. An 11 blade was then used established the portal site. This was followed by insertion of the 4.5mm cannula and ArthroCare wand. Both ArthroCare wand and sucker shaver were used to debride the subacromial bursa. The coracoacromial ligament was left intact. No bursal sided tears were identified in the subacromial space. After completion of the subacromial bursectomy instruments were removed from the shoulder.**
Open subpectoral biceps tenodesis was performed. The patient's arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.*
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.
Hi! The labrum was not repaired, but it was debride. The Rotator Cuff also was not repaired but was debride. The code to use is 29823-Extensive Debridement which consists of the Labrum Debridement, Rotator Cuff Debridement (the capsule w/ the supraspinatus debridementL Also included in the Ext Debride is a Bursectomy, lysis excision/capsular excision and osteophyte excision.
29823 covers all of this. Then there was an Open Bicep Tenotomy 23430. I don't see that a scope partial subacromial decompression was done either +29826.
I would code 23430, 29823. Both allow for ASST.
 
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Need opinions. Now working for new Ortho practice & their dictation is different than I am used to seeing. I would really appreciate if I get another opinion re: codes on this op report. I might just be reading it over to many times and doubting myself. But as I said, I am so used to the transcription from the previous practice I was at. Thanks for your help

After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The circumferential labrum tear was debrided with a sucker shaver and the arthrocare wand. Capsulotomy was performed with sucker shaver and electrocautery device. Attention was paid to the rotator interval which is open from the superior glenohumeral ligament to the subscapularis tendon. Capsule overlying the subscapularis tendon was then debrided and removed. Attention was then paid to the posterior capsule, extending from the 11 o'clock position to the 7 o'clock position the capsule was debrided away. At the inferior aspect of the debridement, the axillary nerve was identified. 7:00 portal was placed into the shoulder and debridement of the osteophyte was performed with sucker shaver, 4 oh bone cutter, and bur. C-arm was used to confirm location on the inferior humeral head. Neural lysis was performed to free of the nerve. *
Instruments were removed from the shoulder and the trocar was redirected into the subacromial space. The subacromial space an 18-gauge needle was placed to localize the lateral portal site and was directly visualized. An 11 blade was then used established the portal site. This was followed by insertion of the 4.5mm cannula and ArthroCare wand. Both ArthroCare wand and sucker shaver were used to debride the subacromial bursa. The coracoacromial ligament was left intact. No bursal sided tears were identified in the subacromial space. After completion of the subacromial bursectomy instruments were removed from the shoulder.**
Open subpectoral biceps tenodesis was performed. The patient's arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.*
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.
The code to use is 29823-Extensive Debridement which consists of the Labrum Debridement, Rotator Cuff Debridement (the capsule w/ the supraspinatus debridementL Also included in the Ext Debride is a Bursectomy, lysis excision/capsular excision and osteophyte excision.
29823 covers all of this. Then there was an Open Bicep Tenotomy 23430. I don't see that a scope partial subacromial decompression was done either +29826.
I would code 23430, 29823. Both allow for ASST.
 
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Need opinion on 29823 documentation. If the provider says on his notes: "an extensive debridement of the glenohumeral joint was performed using the motorized shaver to debride the labrum superiorly and posteriorly back to stable rim." Is this enough documentation to bill a 29823? His finding were "some fraying of anterior and posterior labrum and no significant SLAP type injury or biceps tendinopathy." My superiors are telling me this documentation is not enough to bill this code. Thanks in advance for any help
 

Orthocoderpgu

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29823 can be very tricky because it could be just one area such as significant bone debridement for chondromalacia or may not be met if your debriding a small OCD lesion. In this case the documentation is kind of "on the fence". If the doctor debrided both "Anterior & Posterior" it would meet it. Since this is "Superior & posterior" it's almost there but not quite. My guess is your doc did debridement in another area of the shoulder that you could add to this, such as a tenotomy, and the two together would support 29823. If you want to post a redacted note I would be glad to look at it.
 
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thank you so much for the input. Here's the note. We are billing 29823, 23552 and 29828. BCBS is bundling and other coders think that the 29823 shouldn't be billed in this case because the note is not more specific.


FINDINGS:

20% articular sided supraspinatus tendon tear type II SLAP tear with fraying of the intra-articular biceps

DESCRIPTION OF PROCEDURE:

Patient was placed in the lateral decubitus position and upper extremity was examined and was noted to have full passive range of motion without instability.  The upper extremity was prepped and draped with 10 lb in-line traction was placed across the forearm using a suspension stockinette

The scope was inserted in the glenohumeral joint through a posterior portal and an anterior working portal was created.

An extensive debridement of the glenohumeral joint was performed using the motorized shaver to debride the labrum superiorly and posteriorly back to a stable rim the biceps tenotomy was then performed and the rotator interval was resected the coracoid was identified on both the superior and inferior surfaces

The scope was inserted into the subacromial space and an anterior inflow and lateral working portal were created.  A partial bursectomy was  performed.  The bursal surface of the rotator cuff was noted to be intact

The biceps tendon was then identified the anterior subdeltoid space and accessory anterior inferior portal was created the transverse humeral ligament was divided the biceps tendon was then whipstitched with a #2 FiberWire and secured in an 8 mm socket in the midportion of the bicipital groove using an 8 x 23 Bio-Tenodesis screw

An incision was then made over the distal third of the clavicle to the AC joint sharp dissection was then used to expose the clavicle taking care to preserve a large anterior and posterior periosteal flap at the distal centimeter of the clavicle was resected with a saw on the end of it was contoured

Arthrex arthroscopic guide was then used to pass the pin through the clavicle and through the coracoid followed by drill and then retrograde passage of the dog bone button with the fiber tapes

Sutures were then passed posterior and anterior to the clavicle and medial and lateral to the coracoid for passage of the graft that had been previously prepared acrylic navicular joint was then held slightly over reduced the sutures to the dog bone were then tied to a second dog bone on top of the clavicle for stable fixation the gracilis graft was then passed around the coracoid and anterior and posterior to the clavicle tied to itself and secured with #2 FiberWire the wound was irrigated the periosteal sleeves were closed and oversewn the portal sites were closed​
 

Orthocoderpgu

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There are significant issues with this documentation if you have included everything. 29823 is not supported because the debridement, not related to a restorative procedure, is just debridement of the SLAP. 29828 is documented. There is no supporting diagnosis for 23120 which is usually shoulder arthritis. No diagnosis for 23552. BX does not cover 29823 in general so I am not surprised your having issues with them. They are very behind the times since in 2016 CMS updated the edits to include 29823 if performed with 29824,29827 or 29828 after meeting with the president of AAOS several times. Get with the program BX!
 
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