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Arthroscopy shoulder

  1. Default Arthroscopy shoulder
    Medical Coding Books
    I was wondering how you would code for the following OR. This is just an insert of the report.

    After a diagnostic Arthroscopic shoulder exam is performed:

    Removal of Hardware: The anchor was retrieved uneventfully without difficulty out of the joint and extraction after the suture it was attached to was cut and grasper was required within the intraarticular space to remove this.

    Biceps tenotomy: The biceps was amptuated off of its insertion at the superior labrum. It was debrided back to the point that was well over 50% of involvement and it was cut back and tenotomy was performed. It gently retracted into the bicipital groove. A minor debridement of the intraarticular space was carried out with any loose chondral pieces but no significant debridement or chondroplasty was performed.

    I coded this as 29999 for the bicep tenotomy.....the removal of hardware has me stumped. any thought on 29819 or 20680? Thanks for your help!
    Kelly Sumansky, MA, CPC-H, CMC

  2. #2
    since he actually debrided the biceps stump, I would use the debridement code instead of the unlisted because you can not capture both.

    For the suture removal, I would go with the removal of foreign body, but only if this is the only thing he did in that area.
    Mary, CPC, CANPC, COSC

  3. #3
    Milwaukee WI
    Default What was removed?
    I'm not sure I'm reading this correctly ... was it just the suture that was removed, or was some other hardware (anchor?) also removed?

    If more than just the suture I'd be inclined to go with 20680.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    There was an anchor removed out of the joint.
    Kelly Sumansky, MA, CPC-H, CMC

  5. #5
    assuming that this was an "all scope" procedure, you would need to use 29819 because 20680 is for an open removal....and if I remember correctly (double the cci edits) this is going to bundle with the debridement.
    Mary, CPC, CANPC, COSC

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