Results 1 to 3 of 3

Shoulder Help Please!

  1. Default Shoulder Help Please!
    Medical Coding Books
    Hi Everyone,

    I am really confused on how to code this one. Any guidance would be appreciated.

    PREOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
    2. Long head of biceps tendinitis.
    3. Shoulder impingement.
    4. Acromioclavicular arthritis.

    POSTOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
    2. Long head of biceps tendinitis.
    3. Shoulder impingement.
    4. Acromioclavicular arthritis.

    OPERATION: Right shoulder scope with synovectomy,
    subacromial bursectomy, subacromial
    decompression, distal clavicle resection, and
    biceps tendon tenodesis.
    ANESTHESIA: Interscalene block along with general



    CONDITION: The patient tolerated the procedure well. The patient was
    admitted to the hospital for observation and pain control.

    (patient) who had injured his
    shoulder several months ago after falling off a fence. The patient has
    initially tried physical therapy and had two injections in the shoulder
    without help. The patient was seen in the office and was found to have
    somewhat restricted range of motion along with tenderness to palpation
    at the long head of the biceps. The patient also had positive speed
    test. The patient was scheduled today for shoulder scope with
    synovectomy, bursectomy, and possible long head of the biceps tenodesis.

    PROCEDURE: The patient was seen in the preoperative area. The patient
    was examined. He had tenderness at the acromioclavicular joint. This
    was not the case during his examination in the office. The patient was
    counseled regarding distal clavicle resection. The patient agreed. The
    informed consent was modified to include distal clavicle resection and
    manipulation under anesthesia. The patient's surgical mark on each
    surgical site was marked. The patient was brought to the operating
    room. After induction of general anesthesia, an interscalene block was
    administered. After adequate anesthesia was obtained, the patient was
    positioned in a beach-chair position. The patient's right upper
    extremity was gently manipulated and patient had abduction to about
    160 degrees and forward flexion to about 160 degrees. Internal rotation
    was measured at 90 degrees. The patient had external rotation to
    70 degrees. The patient's right upper extremity was then sterilely
    prepped and draped. A sharp No. 11 blade was used to make a posterior
    portal to the shoulder in a normal manner. Blunt trocar and cannula
    were introduced into the shoulder joint without any difficulty. The
    scope was introduced through the shoulder joint, and the shoulder joint
    was inspected. There appeared to be a moderate amount of synovitis in
    the shoulders, especially in the undersurface of the supraspinatus and
    around the labrum. In addition, there was a moderate amount of
    synovitis at the insertion of the biceps tendon to the labrum. A spinal
    needle was used to locate the anterior portal of the shoulder under
    direct visualization from within the shoulder joint. Blunt trocar was
    then used to create the portal. A switching stick was used to switch
    the metal cannula for a 7-mm cannula. A hooked probe was used
    internally, and the labrum was inspected. There appeared to be good
    solid circumferential attachment of the labrum. Inspection of the
    insertion of the rotator cuff at the footprint revealed a minor amount
    of tissue fraying. The VAPR cautery was introduced from the anterior
    portal and the synovitis was cauterized. Decision was then made to
    tenodese the biceps tendon. Bovie cautery was used to detach the
    attachment of the long head of the biceps from the labrum. After
    detachment of the biceps, the biceps tendon retracted. The rest of the
    shoulder joint was inspected. There were no loose bodies in the
    inferior pouch. There were mild degenerative changes at the glenoid
    fossa, probably grade II changes. A spinal needle was inserted at the
    lateral aspect of the acromion, approximately 1-2 cm distal to the
    lateral edge of the acromion. The spinal needle was used to localize
    the partial thickness tear of the tendon. PDS suture was inserted
    through the spinal needle. The needle was withdrawn, and a suture
    grabber was used to grab the suture from the anterior portal. The
    posterior cannula was withdrawn and reinserted into the subacromial
    space. Inspection of the subacromial space revealed moderate to severe
    amount of synovitis. The VAPR cautery was introduced through the
    anterior portal, and synovectomy was performed all the way to the
    lateral edge of the acromion. The undersurface of the acromion was
    cleared using the VAPR. The anterolateral edge was exposed, and the
    acromioclavicular joint was also exposed. Next, a 0.5-mm Acromionizer
    was introduced from the anterior portal and used to perform a
    subacromial decompression. There was no huge anterolateral osteophyte
    which needed to be resected. Next, the distal clavicle was resected
    using the Acromionizer. We made sure to apply downward pressure on the
    clavicle in order to obtain a complete resection of the distal clavicle.
    The VAPR was again used to cauterize frayed tissues around the distal
    clavicle. The camera was withdrawn and slightly anterior incision was
    made starting at the anterolateral edge of the acromion and extending
    approximately 1.5 inches distally. The anterior raphe of the deltoid
    muscle was exposed, and tissue Freers were used to partition the deltoid
    fibers along its length. The bicipital groove was digitally palpated
    and a sharp No. 15 scalpel blade was used to make a longitudinal
    incision over it. Hemostat was used to retrieve the biceps tendon. A
    Mitek suture anchor was placed in the bicipital groove, and the
    Orthocord sutures were used to suture the biceps tendon to the adjacent
    border of the bicipital groove. The proximal end of the tendon was
    folded over the biceps tendon and sutured using the Orthocord sutures.
    Normal saline irrigation was applied to the incision. Sutures of
    2-0 Vicryl were used to close the deltoid muscle fascia and to close
    subcutaneous tissues using interrupted, inverted sutures. Sutures of
    5-0 Vicryl were used to close the skin. A spinal needle was introduced
    to the glenohumeral joint and an injection of 80 mg methylprednisolone
    along with 8 cc of 0.25% Marcaine without epinephrine was injected into
    the shoulder joint. The portal sites were closed using 5-0 Vicryl.
    Steri-Strips were applied. Sterile dressing was then applied to the
    shoulder, and the patient was awakened by the anesthesia staff. In the
    postoperative area, the patient had no pain at that time. The patient
    had good capillary refill to all of his fingers. The patient will be
    admitted for observation and pain control. The patient will be
    discharged in the morning.

    Thanks for your help

  2. #2
    Hi Amy,

    What codes did you have in mind? I will reply with my thoughts


  3. #3
    Covington, LA
    I would bill 29828/29826/29824/29820-59

Similar Threads

  1. Replies: 3
    Last Post: 02-23-2018, 03:40 PM
  2. Replies: 0
    Last Post: 10-28-2011, 08:44 AM
  3. Shoulder manipulation w/arthroscopic distention of shoulder
    By TLVANDERPOOL in forum Orthopaedics
    Replies: 1
    Last Post: 06-16-2009, 02:06 PM
  4. Shoulder help
    By taurus7694 in forum Orthopaedics
    Replies: 2
    Last Post: 06-05-2009, 02:21 PM
  5. Another shoulder sx
    By cbheusman in forum Orthopaedics
    Replies: 3
    Last Post: 01-08-2009, 10:34 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.