Wiki Shoulder Surgery Coding

cwilson3333

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Would like to see what codes someone else would use on this surgery. Operative note is lengthy, so will try to shorten, but report as much as possible.

DX : Slap lesion of superior labrum with high grade partial tear of rotator cuff and impingement

Procedures Performed: Arthroscopy of right shoulder, subacromial decompression, biceps tenodesis, and mini-open repair of rotator cuff

Procedure: Patient brought into operative theater, placed in supine position. Given general anesthetic, and beach chair elevated about 60 degrees. Given Ancef, prepped and draped in usual sterile fashion.
Scope introduced into glenohumeral joint. Superior labrum had a SLAP tear that was unstable. This was taken down. Rotator cuff had high grade tearing at supraspinatus about 11 mm posterior to biceps. Debrided. Scope introduced into subacromial space, which was very tight. CA ligament resection done; bursectomy preformed. Acromioplasty done for depth of 3-4. Rotator cuff identified. Lateral incision extended to 2 cm laterally. Dissection carried down first to biceps sheath,, which was incised. Biceps delivered into wound.
A 7.5 drill was used to make a tunnel. Irrigated out. Biceps attached to biceps tenodesis anchor from Arthrex with suture through the eyelets, grabbed leaving about 1.5 cm of tendon on proximal portion. This was delivered into tunnel and screwed, very secure. Stitches were tied giving it a kind of pants-over-vest and that was cut. Rotator cuff identified. Bed of bone had already been prepared, and this was fixed in a 2-row technique. Medial row was Corkscrew anchor, double armed, mattress stitches. Lateral was a Swivelock. Watertight closure. Irrigated copiously with sterile saline. Closure done in usual manner, Dressed and wrapped. No complications.

I'm looking at:
23412 for the mini open rotator cuff
23430 for biceps tenodesis
29822 [for debridement/decompression
 
Response

29822 for the labral debridement if it is not a Medicare or Medicaid payer.

Since acromioplasty was done and the patient has impingement, you can use 29826.
 
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