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Coding an arthroscopy

  1. Default Coding an arthroscopy
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    Can someone please tell me how to code....

    DX 1. Large rotator cuff tear, rt shoulder
    2. Glenoid Labral tear
    3. Chronic ruptured long head biceps tendon. rt shoulder

    PROCEDURE
    1. Operative arthroscopy,subacromial decompression, and mini rotator cuff repair, right shoulder
    2. Debridement, laberal tear, right shoulder

    Description of procedure

    A posterior arthroscopic portal was created followed by passage of Wissinger rod exiting lateral to the coracoid process. The joint is inspected. The glenohumeral articular surfaces appear normal. There is an abscense of the long head of the biceps tendon. There was a large retracted rotator cuff tear. There is degenerative tearing of the glenoid labrum which is debrided using a shaver. There is also synovitis which is debrided using a shaver.

    Attention was turned to mini open rotaor cuff repair. An incision was made from the anterolateral edge of the acromion distally. The deltoid was split for approx 2.5 cm. There is an abundance of the bursal tissue which was resected. Minimal bony resection was required and the coracoacromial ligament was left intact. The decompression appears satisfactory.

    There is a large retracted rotaor cuff tear. The tear was grasped and debrided sharply. A rongeur was then used to decorticate the greater tuberosity. Subsequently, repair is carried out using the Arthrex Speedbridge. Initially 2 anchors were placed in the greater tuberosity. The limbs of fiber tape were brought out from the articular surfaceto the bursal surface, taking greater than 1 cm bites. The repair was then tensioned. The fixation appears secure with the sutures. Subsequently the are divided and crisscrossed and 2 additional lateral row anchors are taken and tensioning and bringing the rotator cuff down onto the footprint. The sutures were divided the shoulder was carried through a range of motion the repair appears very secure.

    Codes 23410 was paid while 29828 was denied stating records submitted do not support code.

    I think the appropriate code is 29827? Can someone please tell me if I'm wrong?

    THANK YOU FOR YOUR HELP!!!
    Last edited by Carbon06; 01-13-2017 at 06:09 AM. Reason: more info

  2. #2
    Default
    Quote Originally Posted by Carbon06 View Post
    Can someone please tell me how to code....

    1. Operative arthroscopy,subacromial decompression, and mini rotator cuff repair, right shoulder
    2. Debridement, laberal tear, right shoulder

    Thanks!!

    Usually a "mini repair" is an open procedure...did they go in arthroscopically and realize that an open procedure was necessary?

    Also was the SLAP repaired or just debrided? if repaired you can only code 29807 but if it was just debrided then you only code 29822. Both 29807 and 29822 are bundled services so unless stated in the op note that they are able to have the 59 mod on 29822, only 1 code can be used.


    For subacromial decompression you would code 29826 (if this is coded with the "mini repair" add mod 59 to this code)

    A "mini repair" would be coded 23410 (acute) or 23412 (chronic)

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