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Another shoulder-help please

  1. #1
    Default Another shoulder-help please
    Medical Coding Books
    Post OP DX:
    1. Proximal humerus fracture, right
    2. Osteoporosis
    3. Sumacromial spur
    4. Rotator cuff tear

    1. Open reduction, intramedullary rod fixation of rt humerus
    2. Subacromial decompression

    Brought back to operating suite, prepped and draped in normal sterile fashion. A single incision was made within Langer lines approximately 2 inches long as careful dissection was carried out down to pt's deltoid fascia. The fascia was split at the acromion and subsequently noting immediately the pt had a 1+ centimeter rotator cuff tear as well as significant subacromial spur. This was removed with both a rongeur and a rasp. After it was done the pt was irrigated out. The subacromial bursa was removed and then utilizing a single entry awl a single K-wire was placed in the appropriate position medial to the tuberosity and posterior to the biceps tendon. After this was carefully placed under c-arm fluoroscopy we then placed the second Rush rod posterior to this Rush rod after again developing an entry hole. Xrays taken and reviewed showed anatomic relocation of the fracture. Reanastomosed the deltoid fascia to the acromion and the subcutaneous tissue with 2-0 Vicryl suture and skin with 4-0 Monocryl.

    Thanks in advance for your help!

  2. #2
    see 23615 and see what you think

  3. #3
    Mary, this is the code I was looking at for the fracture. Can we get anything for the rotator cuff tear or subacromial spur? Sorry I don't know why I have such a problem with the shoulder!

  4. #4
    you can probably capture the subacromial spur (check cci edits) but not the rotator cuff, I didnt see any documentation to support a repair of that (unless I overlooked it)

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