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Rotator cuff surgery

  1. Default Rotator cuff surgery
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    Below I have copied an operative report. I coded 29827, 29826, 29807, and 23430. The provider chose 29827,29826,29822, and 23430. Would you please discuss our differences and which codes are correct?

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    Procedure note: The patient is seen and identified in the pre anesthesia holding area: The left shoulder is identified as the operative site, an interscalene nerve block by the anesthesia team in the pre anesthesia holding area. The operative extremity is marked. Informed consent has been obtained in the office. Patient is then taken to the operating room and placed in the hospital stretcher in the supine position. Patient underwent intubation by the anesthesia team. The patient is then positioned in the beach chair position. All neurovascular structures a bony prominences are well padded. The operative shoulder is then pre scrubbed. Sterile prep and drape was then performed. Time-out was performed and antibiotics was confirmed given. Laterality is confirm. Marcaine with epinephrine is then injected into the subacromial space. A standard posterior portal was made with a 11 blade scalpel. The scope is introduced into the glenohumeral joint. Inspection shows normal subscapularis, full-thickness tear of supraspinatus, type 2 slap tear, normal chondral surfaces in the glenohumeral joint. The biceps tendon is tenotomized with the basket forceps. The labrum was debrided to smooth edge. The greater tuberosity is debrided with a combination of motorized shaver, burr and ring curette to a smooth cancellous healing surface. The scope was then placed in the subacromial space. Inspection shows an L-shaped full-thickness rotator cuff tear. Accessory portals are made for suture management. Percutaneous insertion of 2 medial row anchors are then placed from Arthrex at the medial footprint of the rotator cuff loaded with FiberTape. An expressew suture Passer was then used to shuttle sutures into the rotator cuff for medial footprint repair. Suture limbs were then tied in the subacromial space with SMC knots with alternating post half hitches. The suture limbs are then position onto the greater tuberosity laterally and secured with Arthrex anchors and a suture bridge, trans osseous equivalent configuration with excellent repair and reduction of the rotator cuff. An acromioplasty is performed with a bur to a flat surface. The scope was removed. Portals were closed with 4-0 nylon sutures.
    An incision is made in the anterior axillary fold. Blunt dissection was performed under the pectoralis major tendon the biceps is identified in the biceps groove. The biceps tendon is sutured with a #2 FiberWire. An 8 mm unicortical tunnel is drilled directly centered on the biceps groove. The biceps was then tenodesed with an 8x12mm Arthrex PEEK screw. The wound is copiously irrigated and layered closure with 2-0 Vicryl, 4-0 Monocryl, Dermabond and steristrips. All wounds were dressed with 4 x 4, ABD and foam tape. The shoulders immobilized in UltraSling. All the counts are correct, no complications. The patient is awakened from anesthesia and brought to the postanesthesia care unit in excellent condition. With her knowledge of the procedure, Lindsay Campbell directly assisted in critical portions of the procedure including exposure, visualization, assistance with technical aspects of the rotator cuff repair, acromioplasty, closure.

    thanks

  2. #2
    Location
    lawrence, kansas
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    54
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    I agree with the provider that a limited debridement was done, not a labral repair. CPT 29822 will bundle however, most likely into the SAD - 29826. A labral repair is normally done with anchor fixation and seeing as that all that is documented is debridement of the labral tissue, you would not be able to support CPT 29807 with the documentation you have provided.
    Ryan Raich, CPC COSC
    Lawrence, Kansas Chapter President

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