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Help with shoulder surgery for re-injury

  1. #1
    Columbus, Ohio
    Default Help with shoulder surgery for re-injury
    Medical Coding Books
    Hello Coders, I need some help with this. Surgeon did a coracoclavicular ligament reconstruction and the patient re-injured the shoulder, deforming the shoulder. On the first surgery I used 23552 for the dislocation and ligament repair. I have posted the note for the second surgery. How would the reconstruction and ligament repairs be coded this time?
    So far I have 23585, 23120, 20680. Can I use the 23552 again for the AC reduction and ligament repairs? Are there better codes to use? Thanks, Paula in Dublin, Oh

    1. Open reconstruction left shoulder, coracoclavicular ligament.
    2. Open reconstruction left shoulder, AC ligament.
    3. Open treatment left scapula coracoid process fracture with internal
    4. Left shoulder open distal clavicle excision.
    5. Removal of hardware, deep left shoulder.
    6. Left shoulder open reduction and internal fixation, AC joint.

    An oscillating saw was taken to excise 1-cm of the distal clavicle.
    This was removed. The medial aspect the acromion was exposed too. This
    would be for later reconstruction of the AC ligaments. Some of the
    clavicle medially was exposed as well. The Endo button could be seen.
    This was pulled up and the sutures were cut. The biotenodesis screw was
    removed before this as well with the screwdriver. Both Endo buttons
    were retrieved. The graft was pulled out as well that was within the
    Endo button. I did dissect bluntly down to the coracoid process. This
    had been fractured off. The button actually pulled through the entire
    coracoid base. I did extend the incision down to a deltopectoral
    incision for the superior half. Blunt dissection was taken down to the
    deltoid. The deltoid was split in line with the interval. The deltoid
    was tagged with a Vicryl suture. This would be for later repair. Blunt
    dissection was then taken down the coracoid process. The fracture ends
    were freshened with a curette. This was reduced anatomically. A
    guidewire for the 4-0 cannulated screws were placed to the coracoid and
    into the scapula. I used the 2.7-mm drill bit over this.
    I then measured the length and this was a 40-mm screw. I chose a 4.0
    partially threaded cannulated cancellous screw with a washer. I placed
    this in over the wire which compressed and held the coracoid process
    anatomically. This was an excellent repair. The wire was removed. I
    did pass a suture underneath the base before fixation. This is where I
    would pass my graft. I chose a posterior tibial tendon allograft to
    reconstruct the coracoclavicular ligaments. Number 2 FiberWire was
    taken and a whip stitch was placed to both ends of the graft. The graft
    was sized at 6-mm. I passed this underneath the coracoid base using the
    suture loop that I had placed previously. I put one end of the graft
    through the hole in the clavicle from the prior procedure. I then
    drilled a small 3-mm hole at the distal end of the clavicle for
    reconstruction of the AC ligaments. I chose a gracilis allograft for
    this. Number 2 fiber wires were taken at both ends of this graft and it
    was whip stitched. The graft was passed through the distal end of the
    clavicle hole with a Houston suture passer. I did choose a 7 hole
    Synthes hook plate to help hold down the clavicle where the ligament
    I did choose a 15-mm hook. This was placed on the acromion and over
    the grafts on the clavicle and the AC joint was anatomically reduced. A
    3.5 fully threaded cortical screw was placed through one of the medial
    holes in the plate into the shaft after drilling and measuring to the
    appropriate sized length. This pulled the plate to the bone nicely.
    This anatomically reduced the distal clavicle. I placed another 3.5
    fully-threaded cortical screw next to this. The graft through the
    clavicle underneath the coracoid was then tensioned and then tied with a
    #2 FiberWire. This had excellent repair. This was reconstruction of
    the coracoclavicular ligaments. The excess graft was cut with a
    scalpel. I did then place a locking screw through 1 of the holes
    medially in the plate through the shaft as well. The locking guide was
    then used, drilled and measured to the appropriate size length. The
    screw was inserted. I took the graft over the AC joint crossed this
    under the top of the acromion. One suture anchor was placed posterior
    and 1 was placed superior. The graft was tied down with the suture
    I used 3.0 bioabsorbable anchors by Arthrex and placed this in after
    drilling and then tapping this into place through the guide. Again 1
    limb of the graft was placed posterior and 1 was placed superior
    creating a reconstruction of the AC ligaments. This was then tied back
    on itself and sutured with a #2 FiberWire. The excess graft was trimmed
    with the scalpel. The CC and AC ligaments were reconstructed and the
    hook plate was there to hold the reduction while these healed. This was
    anatomic. The coracoid maintained its fixation. The wound was
    copiously irrigated out with normal saline. Vita-Gel soft tissue
    autograft was injected deeply. The deltoid was approximated back to the
    clavicle through the drill holes. This was done with a #2 FiberWire.
    The deltoid was repaired back on itself, as well as the deep fascia with
    a #2 FiberWire. This was oversewn with #1 Vicryl. The skin was
    approximated with 2-0 Vicryl and then staples placed on the skin. Local
    anesthetic was injected. A sterile dressing was applied as well as cold
    therapy pack placed over the gown. The arm was placed in an
    immobilizer. The patient was then awoken from anesthesia without
    complication, and transferred to the post anesthesia care unit in stable

  2. Default
    I agree with your codes;
    But what I feel is:
    CPT 20680 is bundled. Can avoid.
    CPT 23552 can be coded again. Because this is a new operation.

  3. Default
    I was coming up with the same codes. I am a student getting ready to go on externship and I am glad that I am heading in the right direction. For number 6 on your list, could you code 23101 and 23700 or is there a bundled code for that procedure that I am overlooking?

  4. #4
    Columbus, Ohio
    Thank you coders for your responses. Regarding the last procedure, the 23101 is inclusive according to the AAOS global book and I think the manipulation would also be inclusive. Does anyone agree with that or have comments? Thanks again, Paula

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