DX: Chronic rotator cuff tear which was deemed irreparable
Biceps tendon fraying greater than 50%
Left shoulder pain
PROC: Arthroscopic subacromial decompression
coplaning distal clavicle
In the body of the operative report doc reports Grade I chondromalacial changes over the gelnoumeral surfaces, distal calvicle spur impinging on the rotator cuff. According to op note the only thing done to the rotator cuff was "extensive mobilization under tension"
Any ideas would be appreciated. I used 29828 (no arthroscopic tenotomy), 29824-59, 29826-59??????
I would not bill 29826 unless a partial acromioplasty was also done with the decompression of subacromial space. 29828 is for tenodesis, which is sewing of the biceps tendon. For biceps tenotomy, which is cutting of the tendon, there is no cpt for arthroscopic so unlisted 29999 is needed. AAOS recommends that 29824 only be charged if 1cm or 8-10mm of the clavicle is removed. I have my docs document exactly how much bone is removed just to cover all our back-sides. Without seeing the whole note is difficult to tell you exactly what should have been coded.
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