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2nd request RC repair

  1. Default 2nd request RC repair
    Medical Coding Books
    our doctor feels he did a biceps tenodesis (29828) and a RC repair (29827) but I'm not sure about the RC repair! please take a look

    "a severely retracted rotator cuff was identified with the supraspinatus retracted beyond the edge of the superior glenoid. A release was performed of the adhesions, which did not adequately pull the supraspinatus back over the humeral head. There was superior migration of humeral head. therefore a tenodesis was performed with the biceps being sutured to the infraspinatus tendon once the release was performed and the subscapularis sutured to the biceps tendon. the procedure was performed with an anterior and posterior cannula. The arthroscope was placed in a direct lateral portal. multiple #2 fiberwire sutures were placed using a 45 degree suture passer and a straight bird beak in a hand off fashion. Sutures were placed from medial to lateral. Once the suture was retrieved, the suture knot pusher was placed on both limbs to make sure it was untangled. A Duncan loop was used, two half-hitches, reverse half hitch, and a reverse post. Then the knots were cut leaving a tag with Fiberwire arthroscopic cutter. Once this was accomplished and the head was covered, The bursa was debrided but a subacromial decompression was not performed since there was already superior migration of the humeral head"

  2. #2
    His documentation is very weak, but there. He kinda threw me off by mentioning the supraspinatous, but does the repair on the subscapularis.
    Mary, CPC, CANPC, COSC

  3. Default
    maybe where he says "subscapularis sutured to biceps tendon" which is not usually the way it goes,

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