dsibley67
Networker
I am having difficulty coding. I have researched, and everything I have found is different in reporting remplissage. One says to code 29806 -22, another says to code 29806-LT, 29806-59 LT, and 29806 -lt, 29999-lt and compare it to 29827. I am so confused. What is your suggestion on how to code this properly? Here is the op note, just in case you need it. Any help will be greatly appreciated. Thanks!
POSTOPERATIVE DIAGNOSES:
1. Left shoulder Bankart lesion with shoulder instability.
2. Left shoulder Hill-Sachs deformity.
PROCEDURES PERFORMED:
1. Left shoulder arthroscopy with labral repair.
2. Left shoulder arthroscopy with remplissage via infraspinatus tenodesis.
3. Left shoulder arthroscopy with extensive debridement.
On the morning of surgery, the patient was met in the
preoperative holding area. Prior to initiation of any medication, the operative extremity was marked with
indelible pen. The appropriate laterality was confirmed verbally with the patient. Any remaining questions
were answered in their entirety. The patient was taken to the operative suite, where general anesthesia
with an LMA was administered by the Anesthesia Team. He was first underwent an exam under
anesthesia at that time. He had greater than two quadrants of anterior glide with hyperlaxity in the
anterior direction when compared with the contralateral side. I was able to dislocate and then relocate
him. He did not have any increased glide in the posterior direction. No increased sulcus. We then placed
the patient in the lateral decubitus position with the affected extremity aimed to the ceiling. An axillary roll
was used. The extremities were padded at all bony prominences. The left upper extremity was prepped
and draped in usual sterile fashion. Formal time-out to include the administration of antibiotics, appropriate
laterality, availability of all necessary implants, and any questions or concerns by surgical team were
addressed and confirmed.
I then marked out the bony landmarks of the lateral portion of the shoulder to include the lateral acromion,
the scapular spine, the AC joint, anterior clavicle and Neviaser portal as well as the coracoid. I used an 11
blade to make an incision for the posterior portal. A blunt scope trocar was then entered into the posterior
glenohumeral joint. The arthroscope was introduced and a diagnostic arthroscopy was completed. There
was a large anterior to anteroinferior labral tear with some minimal appreciable anterior bone loss. There
was an appreciable Hill-Sachs deformity. With rotation, it was non-engaging. There was no obvious tear
of the SLAP or biceps labral complex. He did have significant grade 3 chondromalacia present adjacent
to the labral tear on the humeral head. There was small focus of cartilage loss on the glenoid, but the
majority of the cartilage was intact. The rotator cuff appeared unremarkable except for the undersurface
area of the infraspinatus that showed injury secondary to his Hill-Sachs deformity. The biceps was
maintained normally in the sling and in normal position without tearing.
Focus was then turned on creating working portals. A high anterosuperior lateral portal was created and a
6 mm cannula was introduced. I then placed an anterior mid glenoid portal just superior to the
subscapularis and an 8.25 mm cannula was placed there. Once the portals were created, I used an
arthroscopic shaver with a liberator to define the labral tearing. He did have some transition of the tear
around to the posteroinferior glenohumeral ligament. At that time, I turned my attention to placement of a
7 o'clock anchor. First, I used the Arthrex percutaneous kit to create a low posterior portal
percutaneously. Once I had appropriate trajectory, the drill guide was introduced and a 1.8 mm FiberTak
anchor was placed near the posteroinferior glenohumeral ligament. I then turned my camera to the
anterosuperior portal and used a lasso through the posterior portal to advance the posteroinferior
glenohumeral ligament through the capsule and the labrum. This allowed us to plicate the posteroinferior
capsular tissue. Once I was happy with this anchor placement, I then through the same portal was able to
visualize the Hill-Sachs lesion. I removed the posterior cannula from inside the joint to the subacromial
space over the top of the infraspinatus tendon. I then placed two 1.8 mm FiberTak anchors into the
Hill-Sachs defect through the infraspinatus tendon to allow for later tenodesis to complete the remplissage
via infraspinatus repair/tenodesis into the defect. I first placed the inferior anchor and then placed the
superior anchor. I provisionally passed a knotless mechanism, but did not completely tighten it at this time.
I then removed the cannula and with a switching stick, reestablished the posterior portal. I then moved
the camera back to the posterior portal and began working on the anterior portion of the labrum. At the
anteroinferior portion, I placed another 1.8 mm FiberTak anchor. The suture lasso was passed through the
anteroinferior glenohumeral ligament and labral tissue to allow for anterior capsular plication. After
passage of this, I then passed a large FiberTape in a mattress fashion through the superior portion of the
anteroinferior glenohumeral ligament and the anterior capsule and passed this through an Arthrex
PushLock anchor. The drill hole was made and the anchor was placed with nice restoration of the
anterior and inferior bumper. There was one remaining portion of anterior capsular tissue just inferior to
the subscapularis that I placed an additional 1.8 mm FiberTak anchor through in a similar fashion to
complete the anterior plication. This was below the 3 o'clock position in the sublabral foramen. This
completed the anterior labral repair.
Viewing from the anterosuperior portal, I then sequentially tightened the remplissage anchors. This
completed the remplissage via infraspinatus tenodesis into the defect.
I then used a bird-beak with a 0 PDS through the posterior portal to close the posterior portal. All
permanent arthroscopic images were saved. Viewing from the anterosuperior portal, there was great
restoration of the capsular bumper at the posteroinferior, anteroinferior and anterior portions of the glenoid.
There was good centering of the humeral head. No obvious translation. All instruments were removed.
Surgical counts were correct. I drained the excess fluid from the sutures. The portals were closed with
3-0 nylon sutures. A sterile dressing was applied. The patient was placed into abduction sling. He was
awakened from anesthesia and transferred to PACU in stable condition.
POSTOPERATIVE PLAN: The patient will be on the capsulorrhaphy and remplissage protocol. I will
plan to see him in the office in two weeks for suture removal and assurance of good early recovery in
appropriate motion. He will be in a sling for a minimum of six weeks. He has aspirin for DVT
chemoprophylaxis and appropriate postoperative pain control. He will plan to contact the office or present
to the nearest emergency room with any acute medical conditions.
POSTOPERATIVE DIAGNOSES:
1. Left shoulder Bankart lesion with shoulder instability.
2. Left shoulder Hill-Sachs deformity.
PROCEDURES PERFORMED:
1. Left shoulder arthroscopy with labral repair.
2. Left shoulder arthroscopy with remplissage via infraspinatus tenodesis.
3. Left shoulder arthroscopy with extensive debridement.
On the morning of surgery, the patient was met in the
preoperative holding area. Prior to initiation of any medication, the operative extremity was marked with
indelible pen. The appropriate laterality was confirmed verbally with the patient. Any remaining questions
were answered in their entirety. The patient was taken to the operative suite, where general anesthesia
with an LMA was administered by the Anesthesia Team. He was first underwent an exam under
anesthesia at that time. He had greater than two quadrants of anterior glide with hyperlaxity in the
anterior direction when compared with the contralateral side. I was able to dislocate and then relocate
him. He did not have any increased glide in the posterior direction. No increased sulcus. We then placed
the patient in the lateral decubitus position with the affected extremity aimed to the ceiling. An axillary roll
was used. The extremities were padded at all bony prominences. The left upper extremity was prepped
and draped in usual sterile fashion. Formal time-out to include the administration of antibiotics, appropriate
laterality, availability of all necessary implants, and any questions or concerns by surgical team were
addressed and confirmed.
I then marked out the bony landmarks of the lateral portion of the shoulder to include the lateral acromion,
the scapular spine, the AC joint, anterior clavicle and Neviaser portal as well as the coracoid. I used an 11
blade to make an incision for the posterior portal. A blunt scope trocar was then entered into the posterior
glenohumeral joint. The arthroscope was introduced and a diagnostic arthroscopy was completed. There
was a large anterior to anteroinferior labral tear with some minimal appreciable anterior bone loss. There
was an appreciable Hill-Sachs deformity. With rotation, it was non-engaging. There was no obvious tear
of the SLAP or biceps labral complex. He did have significant grade 3 chondromalacia present adjacent
to the labral tear on the humeral head. There was small focus of cartilage loss on the glenoid, but the
majority of the cartilage was intact. The rotator cuff appeared unremarkable except for the undersurface
area of the infraspinatus that showed injury secondary to his Hill-Sachs deformity. The biceps was
maintained normally in the sling and in normal position without tearing.
Focus was then turned on creating working portals. A high anterosuperior lateral portal was created and a
6 mm cannula was introduced. I then placed an anterior mid glenoid portal just superior to the
subscapularis and an 8.25 mm cannula was placed there. Once the portals were created, I used an
arthroscopic shaver with a liberator to define the labral tearing. He did have some transition of the tear
around to the posteroinferior glenohumeral ligament. At that time, I turned my attention to placement of a
7 o'clock anchor. First, I used the Arthrex percutaneous kit to create a low posterior portal
percutaneously. Once I had appropriate trajectory, the drill guide was introduced and a 1.8 mm FiberTak
anchor was placed near the posteroinferior glenohumeral ligament. I then turned my camera to the
anterosuperior portal and used a lasso through the posterior portal to advance the posteroinferior
glenohumeral ligament through the capsule and the labrum. This allowed us to plicate the posteroinferior
capsular tissue. Once I was happy with this anchor placement, I then through the same portal was able to
visualize the Hill-Sachs lesion. I removed the posterior cannula from inside the joint to the subacromial
space over the top of the infraspinatus tendon. I then placed two 1.8 mm FiberTak anchors into the
Hill-Sachs defect through the infraspinatus tendon to allow for later tenodesis to complete the remplissage
via infraspinatus repair/tenodesis into the defect. I first placed the inferior anchor and then placed the
superior anchor. I provisionally passed a knotless mechanism, but did not completely tighten it at this time.
I then removed the cannula and with a switching stick, reestablished the posterior portal. I then moved
the camera back to the posterior portal and began working on the anterior portion of the labrum. At the
anteroinferior portion, I placed another 1.8 mm FiberTak anchor. The suture lasso was passed through the
anteroinferior glenohumeral ligament and labral tissue to allow for anterior capsular plication. After
passage of this, I then passed a large FiberTape in a mattress fashion through the superior portion of the
anteroinferior glenohumeral ligament and the anterior capsule and passed this through an Arthrex
PushLock anchor. The drill hole was made and the anchor was placed with nice restoration of the
anterior and inferior bumper. There was one remaining portion of anterior capsular tissue just inferior to
the subscapularis that I placed an additional 1.8 mm FiberTak anchor through in a similar fashion to
complete the anterior plication. This was below the 3 o'clock position in the sublabral foramen. This
completed the anterior labral repair.
Viewing from the anterosuperior portal, I then sequentially tightened the remplissage anchors. This
completed the remplissage via infraspinatus tenodesis into the defect.
I then used a bird-beak with a 0 PDS through the posterior portal to close the posterior portal. All
permanent arthroscopic images were saved. Viewing from the anterosuperior portal, there was great
restoration of the capsular bumper at the posteroinferior, anteroinferior and anterior portions of the glenoid.
There was good centering of the humeral head. No obvious translation. All instruments were removed.
Surgical counts were correct. I drained the excess fluid from the sutures. The portals were closed with
3-0 nylon sutures. A sterile dressing was applied. The patient was placed into abduction sling. He was
awakened from anesthesia and transferred to PACU in stable condition.
POSTOPERATIVE PLAN: The patient will be on the capsulorrhaphy and remplissage protocol. I will
plan to see him in the office in two weeks for suture removal and assurance of good early recovery in
appropriate motion. He will be in a sling for a minimum of six weeks. He has aspirin for DVT
chemoprophylaxis and appropriate postoperative pain control. He will plan to contact the office or present
to the nearest emergency room with any acute medical conditions.
