I have a question on coding a subacromial decompression, should this be coded as 29826 or with debridement codes 29822/29823. The subacromial decompression was done by removing a spur (the definition of bone spur is an osteophyte) Per an article I read on the AAPC website states that removing an osteophytes would not be considered an acromioplasty and should be reported as a debridement. The confusion is that the osteophyte is a bony growth. Any help would be greatly appreciated.
Actual Procedures
p Right Shoulder Arthroscopy, Rotator Cuff Repair with Allograft, Subacromial Decompression, Labral Debridement, Open Biceps Tenodesis, Open Distal Clavicle Excision(Right)
We initiated the procedure by creating a standard posterior viewing portal for beach chair arthroscopy. Cursory diagnostic arthroscopy was carried out and an anterior portal was established using a spinal needle for localization. A motorized shaver was then introduced to address synovitis and improve visualization. Thorough diagnostic arthroscopy was carried out.
The superior labrum had chronic appearing tear that was near full-thickness. There was labral tissue subluxated over the face of the glenoid. The posterior labrum was frayed and tear and the chondral labral junction extended to approximately 7:00 posteriorly. The labral tissue remained lateralized and healthy appearing. Labral debridement was performed using the torpedo motorized shaver. The superior labrum was unloaded by a biceps tenotomy, for later tenodesis. There is significant synovitis in the rotator interval and in and around the subscapularis. This was all debrided using motorized shaver. The underside of the infra and supraspinatus had high-grade partial-thickness tearing and abrasive qualities to it. There is a flap tear based at the anterior cable insertion on the humeral head. This was all devitalized and chronically torn. A generalized debridement of this area was performed. There was greater than 50% uncovering the rotator cuff footprint with this articular sided tear with tissue deficiency. There was also an obvious split at the infraspinatus and supraspinatus junction. A spinal needle and PDS was placed here to mark it for the subacromial space. Cartilage was mostly intact throughout. Subscapularis had some insertional fraying that was debrided. Otherwise was intact.
We then exited the intra-articular space and entered the subacromial space using a trocar. Lateral working portal was established using a spinal needle for localization. Motorized shaver was introduced and that subacromial bursectomy was carried out to improve visualization.
A spur was appreciated on the anterior lateral edge of the acromion. A formal subacromial decompression was performed using motorized bur to reduce this back to a flat stable margin. Thorough irrigation was then performed.
Once we have adequate visualization of the rotator cuff we evaluated the bursal aspect. We then changed to the lateral viewing portal. Switching stick was used to assist with this. Spinal needle was then used to create an accessory lateral viewing portal. We then cannulated the original lateral portal with an Arthrex Gemini cannula, and the viewing portal was cannulated with an Arthrex silicone passport. Debridement of the rotator cuff bursal side was carried out. There was noticeable tendinosis and yellowing of the tissue throughout. There was some bare fibers that were debrided. We debrided back generative rotator cuff tissue back to stable tissue margins. The split tear was accessed using the torpedo motorized shaver and the rotator cuff footprint was debrided through there. An Arthrex microfracture awl was then used to perform trans tendon microfracture of the greater tuberosity footprint for marrow stimulation.
The camera is placed back into the joint to view the articular margin. Spinal needle was used to localize an in situ anchor at the margin. Switching stick was used to penetrate through the tissue and marker spot for the anchor. We then used the cannulated guide to place fiber tacks. 3 fiber tacks were needed because of the span of the tear. Tear was then placed in the subacromial space once again.
Because of the diffuse tendinosis and greater than for percent thinning of the tendon, we chose to do allograft augmentation repair with these in situ anchors. The knotless mechanism was then used to shuttle in the medial side of the graft firmly against anchor positions. The graft was repaired laterally using Arthrex 3.5 mm self punching push locks which spread the graft over the repair site and tendinosis.
The tails were then brought back out the lateral portal. We used a Arthrex Gemini cannula to provisionally reduce the tissue using the suture tails. We chose our spot for the lateral row anchor based on a quality reduction of the Arthroflex graft. The punch was used to create the hole for the anchor. A 4.75 mm bio composite swivel lock anchor was then loaded with these tails and deployed into its socket under arthroscopic visualization. This was repeated for the posterior lateral anchor position to complete the repair. The tear repair was then evaluated. Had good reduction of tissue and complete coverage of the footprint and tendinosis
The subacromial space was then thoroughly irrigated and evacuated of arthroscopic fluid. Intra-articular exam demonstrated near anatomic reduction of the tissue. Joint was deflated of arthroscopic fluid as well. All instruments were then removed including the cannulas.
A 3 cm incision was made over the AC joint in line with the joint. Subcutaneous dissection was carried out down to the capsular tissue. A perpendicular arthrotomy was made and elevated using electrocautery to expose the distal clavicle. A 10 mm sagittal saw blade was then used to perform an 8 mm resection of the distal clavicle. Rongeur was used to remove fibrinous debris from the joint. The joint was then thoroughly irrigated. The inferior capsule was intact. The superior capsular arthrotomy was then approximated using 0 Vicryl suture. Subcutaneous dissection was repaired using 0 Vicryl suture. The skin was closed with 3-0 and 4-0 Monocryl in the dermal layer.
The arm was positioned in slight abduction and neutral rotation to allow access to the axilla. A 2 cm incision was planned at the leading edge of the axillary fold on the arm. The skin was anesthetized with 10 cc of quarter percent Marcaine with epinephrine. Incision was made. Soft tissue dissection was carried out. Hemostasis was achieved with Bovie electrocautery. The fascia was approached and the subdeltoid area was entered. The pec tendon was palpated. The bicipital groove was then palpated. The biceps tendon was identified in the groove and extricated from the wound using a right angle hemostat. The tendon was debrided using a Ray-Tec of all soft tissue and tenosynovitis. A whipstitch was performed using a fiber loop suture starting at the musculotendinous junction and advancing 2 cm with 4-5 throws. The remainder of the tendon stump was cut and discarded. The fiber loop was cut and loaded onto the knotless fibertak mechanisms. The distal aspect of the bicep groove in the subpectoral region was then prepared. The soft tissue was removed using a combination of electrocautery and arthroscopic rasp down to bleeding bone. The deltoid and pec were retracted superior laterally and the 2.6 mm Arthrex guidepin was drilled through the anterior cortex. The Knotless Fibertak was then deployed into this hole after pulling the guidepin out. Suture tails were pulled to ensure the Fibertak was well fixed in the intramedullary canal. The toggle mechanism of the Fibertak was then used to pull the tendon down into it prepared anterior humeral tenodesis site. Free needle was used to pass suture tails back through the tendon stump. A firm knot was then tied on the anterior aspect to paste it down to complete the biceps tenodesis in the subpectoral region. The area was thoroughly irrigated. Closure was conducted with a running 4-0 Monocryl suture in the fascial layer, followed by interrupted subcuticular sutures of 4-0 Monocryl with a buried knot. This was backed up by both Dermabond and Steri-Strips.
Wounds were approximated using 3-0 Monocryl suture in a buried knot fashion, backed up by Steri-Strips. The wounds are dressed sterile Xeroform, sterile gauze and ABD. Ioban tape was then used to secure the final dressing. The arm was placed in a standard postoperative sling.
Patient tolerated the procedure well, was extubated in the operating room without complication, and transported the PACU in stable condition.
Actual Procedures
p Right Shoulder Arthroscopy, Rotator Cuff Repair with Allograft, Subacromial Decompression, Labral Debridement, Open Biceps Tenodesis, Open Distal Clavicle Excision(Right)
We initiated the procedure by creating a standard posterior viewing portal for beach chair arthroscopy. Cursory diagnostic arthroscopy was carried out and an anterior portal was established using a spinal needle for localization. A motorized shaver was then introduced to address synovitis and improve visualization. Thorough diagnostic arthroscopy was carried out.
The superior labrum had chronic appearing tear that was near full-thickness. There was labral tissue subluxated over the face of the glenoid. The posterior labrum was frayed and tear and the chondral labral junction extended to approximately 7:00 posteriorly. The labral tissue remained lateralized and healthy appearing. Labral debridement was performed using the torpedo motorized shaver. The superior labrum was unloaded by a biceps tenotomy, for later tenodesis. There is significant synovitis in the rotator interval and in and around the subscapularis. This was all debrided using motorized shaver. The underside of the infra and supraspinatus had high-grade partial-thickness tearing and abrasive qualities to it. There is a flap tear based at the anterior cable insertion on the humeral head. This was all devitalized and chronically torn. A generalized debridement of this area was performed. There was greater than 50% uncovering the rotator cuff footprint with this articular sided tear with tissue deficiency. There was also an obvious split at the infraspinatus and supraspinatus junction. A spinal needle and PDS was placed here to mark it for the subacromial space. Cartilage was mostly intact throughout. Subscapularis had some insertional fraying that was debrided. Otherwise was intact.
We then exited the intra-articular space and entered the subacromial space using a trocar. Lateral working portal was established using a spinal needle for localization. Motorized shaver was introduced and that subacromial bursectomy was carried out to improve visualization.
A spur was appreciated on the anterior lateral edge of the acromion. A formal subacromial decompression was performed using motorized bur to reduce this back to a flat stable margin. Thorough irrigation was then performed.
Once we have adequate visualization of the rotator cuff we evaluated the bursal aspect. We then changed to the lateral viewing portal. Switching stick was used to assist with this. Spinal needle was then used to create an accessory lateral viewing portal. We then cannulated the original lateral portal with an Arthrex Gemini cannula, and the viewing portal was cannulated with an Arthrex silicone passport. Debridement of the rotator cuff bursal side was carried out. There was noticeable tendinosis and yellowing of the tissue throughout. There was some bare fibers that were debrided. We debrided back generative rotator cuff tissue back to stable tissue margins. The split tear was accessed using the torpedo motorized shaver and the rotator cuff footprint was debrided through there. An Arthrex microfracture awl was then used to perform trans tendon microfracture of the greater tuberosity footprint for marrow stimulation.
The camera is placed back into the joint to view the articular margin. Spinal needle was used to localize an in situ anchor at the margin. Switching stick was used to penetrate through the tissue and marker spot for the anchor. We then used the cannulated guide to place fiber tacks. 3 fiber tacks were needed because of the span of the tear. Tear was then placed in the subacromial space once again.
Because of the diffuse tendinosis and greater than for percent thinning of the tendon, we chose to do allograft augmentation repair with these in situ anchors. The knotless mechanism was then used to shuttle in the medial side of the graft firmly against anchor positions. The graft was repaired laterally using Arthrex 3.5 mm self punching push locks which spread the graft over the repair site and tendinosis.
The tails were then brought back out the lateral portal. We used a Arthrex Gemini cannula to provisionally reduce the tissue using the suture tails. We chose our spot for the lateral row anchor based on a quality reduction of the Arthroflex graft. The punch was used to create the hole for the anchor. A 4.75 mm bio composite swivel lock anchor was then loaded with these tails and deployed into its socket under arthroscopic visualization. This was repeated for the posterior lateral anchor position to complete the repair. The tear repair was then evaluated. Had good reduction of tissue and complete coverage of the footprint and tendinosis
The subacromial space was then thoroughly irrigated and evacuated of arthroscopic fluid. Intra-articular exam demonstrated near anatomic reduction of the tissue. Joint was deflated of arthroscopic fluid as well. All instruments were then removed including the cannulas.
A 3 cm incision was made over the AC joint in line with the joint. Subcutaneous dissection was carried out down to the capsular tissue. A perpendicular arthrotomy was made and elevated using electrocautery to expose the distal clavicle. A 10 mm sagittal saw blade was then used to perform an 8 mm resection of the distal clavicle. Rongeur was used to remove fibrinous debris from the joint. The joint was then thoroughly irrigated. The inferior capsule was intact. The superior capsular arthrotomy was then approximated using 0 Vicryl suture. Subcutaneous dissection was repaired using 0 Vicryl suture. The skin was closed with 3-0 and 4-0 Monocryl in the dermal layer.
The arm was positioned in slight abduction and neutral rotation to allow access to the axilla. A 2 cm incision was planned at the leading edge of the axillary fold on the arm. The skin was anesthetized with 10 cc of quarter percent Marcaine with epinephrine. Incision was made. Soft tissue dissection was carried out. Hemostasis was achieved with Bovie electrocautery. The fascia was approached and the subdeltoid area was entered. The pec tendon was palpated. The bicipital groove was then palpated. The biceps tendon was identified in the groove and extricated from the wound using a right angle hemostat. The tendon was debrided using a Ray-Tec of all soft tissue and tenosynovitis. A whipstitch was performed using a fiber loop suture starting at the musculotendinous junction and advancing 2 cm with 4-5 throws. The remainder of the tendon stump was cut and discarded. The fiber loop was cut and loaded onto the knotless fibertak mechanisms. The distal aspect of the bicep groove in the subpectoral region was then prepared. The soft tissue was removed using a combination of electrocautery and arthroscopic rasp down to bleeding bone. The deltoid and pec were retracted superior laterally and the 2.6 mm Arthrex guidepin was drilled through the anterior cortex. The Knotless Fibertak was then deployed into this hole after pulling the guidepin out. Suture tails were pulled to ensure the Fibertak was well fixed in the intramedullary canal. The toggle mechanism of the Fibertak was then used to pull the tendon down into it prepared anterior humeral tenodesis site. Free needle was used to pass suture tails back through the tendon stump. A firm knot was then tied on the anterior aspect to paste it down to complete the biceps tenodesis in the subpectoral region. The area was thoroughly irrigated. Closure was conducted with a running 4-0 Monocryl suture in the fascial layer, followed by interrupted subcuticular sutures of 4-0 Monocryl with a buried knot. This was backed up by both Dermabond and Steri-Strips.
Wounds were approximated using 3-0 Monocryl suture in a buried knot fashion, backed up by Steri-Strips. The wounds are dressed sterile Xeroform, sterile gauze and ABD. Ioban tape was then used to secure the final dressing. The arm was placed in a standard postoperative sling.
Patient tolerated the procedure well, was extubated in the operating room without complication, and transported the PACU in stable condition.