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Rotator Cuff w Bursa

  1. #1
    Dane County - WI
    Default Rotator Cuff w Bursa
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    My Dr. is doing a Arthroscopy & Debridement of rotator cuff tear. During the approach to the rotator cuff he found a bursa and removed it. Below is the surgery note. I am having trouble deciding if the bursa was incidental or should be picked up. If I pick it up the only code I can find that seems appropriate is 23076. Please help me with this one.

    Attention was then paid to the mini-open repair. An incision was made incorporating the prior lateral portal site. Dissection continued through the fibers of the deltoid to the subacromial space. It was difficult to determine but it looked like that there was extensive bursa formation that actually looked a lot like rotator cuff but on further inspection there was a retracted posterior portion of the cuff that was adhered to the bursa. This was separated from the bursal tissue and this separation proceeded anterior superiorly. The excess bursal tissue was then removed.

    The remaining rotator cuff tissue had to be mobilized extensively, freeing it from any scar tissue. The anticipated repair site for a double row repair was then freshened with a rasp. The proximal row of anchors was placed. This was pulling the rotator cuff as far anterior as possible but there was an anterior defect present. These anchor sutures were tied through the rotator cuff about 1 cm proximal to the end of the tendon. Because of the nature of the cuff tear, the fact that it had torn before, and the deficient nature of the cuff, it was felt that using the Tissue Mend to augment the repair soft tissue matrix was reasonable. Therefore, the free needle was used to pass the proximal row of sutures through the Tissue Mend graft matrix. The 2nd row of anchors was then placed securing the graft matrix

    Thanks Kate

  2. #2
    Sounds incidental to me. In the lay description of an arthroscopic repair, a limited bursectomy would be included. Also, there doesn't seem to be any serious pathology connected with the bursa, just adherence to the RC. Under AAOS guidelines excision of bursa is included in the mini-open repair. 23412 is generally used for a mini-open repair.
    Last edited by coderguy1939; 05-01-2009 at 08:45 AM. Reason: AAOS guidelines

  3. Default
    I also say it would be incidental.

  4. #4
    Dane County - WI
    Thanks for confirming my thoughts.


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