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Help with Shoulder Repair

  1. Question Help with Shoulder Repair
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    I need help, please!!! Please read the following op report & tell me how you would code & if my codes are correct: Diagnostic arthroscopy revealed grade2 chondromalacia over the humeral head & over the glenoid. There also was some tearing over the anterior labrum. The biceps tendon was firmly anchored, but there was evidence of a full-thickness rotator cuff tear. I went ahead through the anterior portal & debrided the labrum & the humeral head & the glenoid. I also debrided the undersurface of the rtc. It appeared to be a long split-type tear. I removed the scope from the intra-articular position & placed it in the posterior subacromial space & removed the periosteum over the anterior acromion & the distal clavicle. I then performed an acromioplasty & a partial distal clavicle excision. I resected the corocoacromial ligament. At that point, I went ahead & made a small incision anterior to the shoulder girdle, just lateral to the AC joint, carried this through the deltoid fibers down onto the rotator cuff tendon. It had a split & several sutures were used to repair this tendon.
    My codes: 23412 for the mini-open; 29826 for the acromioplasty; 29824 for the distal clavicle excision & 29822-59 for the debridement of the glenohumeral joint. I had another coder look at & she came up with 23412 & 29824. She is telling me I can't use 29826 due to it being inclusive of 23412? I'm confused. Any assistance, guidance would be greatly appreciated. Thank you in advance. Jody Hecht

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    Quote Originally Posted by Jody Hecht View Post
    I need help, please!!! Please read the following op report & tell me how you would code & if my codes are correct: Diagnostic arthroscopy revealed grade2 chondromalacia over the humeral head & over the glenoid. There also was some tearing over the anterior labrum. The biceps tendon was firmly anchored, but there was evidence of a full-thickness rotator cuff tear. I went ahead through the anterior portal & debrided the labrum & the humeral head & the glenoid. I also debrided the undersurface of the rtc. It appeared to be a long split-type tear. I removed the scope from the intra-articular position & placed it in the posterior subacromial space & removed the periosteum over the anterior acromion & the distal clavicle. I then performed an acromioplasty & a partial distal clavicle excision. I resected the corocoacromial ligament. At that point, I went ahead & made a small incision anterior to the shoulder girdle, just lateral to the AC joint, carried this through the deltoid fibers down onto the rotator cuff tendon. It had a split & several sutures were used to repair this tendon.
    My codes: 23412 for the mini-open; 29826 for the acromioplasty; 29824 for the distal clavicle excision & 29822-59 for the debridement of the glenohumeral joint. I had another coder look at & she came up with 23412 & 29824. She is telling me I can't use 29826 due to it being inclusive of 23412? I'm confused. Any assistance, guidance would be greatly appreciated. Thank you in advance. Jody Hecht


    I would use 23412 and 29823 (for debridement of the glenoid, humeral head and labrum).

    There is not enough documentation to support 29826 or 29824. He only states "I then performed an acromioplasty & a partial distal clavicle excision. I resected the corocoacromial ligament.". He needs to tell you how he accomplished both of these surgeries. Stating he performed them alone is not enough. He needs to document how much of the distal clavicle was excised (8mm + to qualify for 59 modifier). Did he convert the acromion to a type I or II? The documentation really stinks!!
    Mary, CPC, CANPC, COSC

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