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Shoulder surgery - new one

  1. Default Shoulder surgery - new one
    Medical Coding Books
    Sorry guys!

    Need help with this one. Wondering if anyone has seen this procedure before. Can only think of using 29806-22 to indicate additional work using the awl to address the microfracture and then removal of loose bodies. Any input would be appreciated.


    PREOPERATIVE DIAGNOSIS: Right shoulder posterior labral tear.

    POSTOPERATIVE DIAGNOSIS: Right shoulder posterior labral tear.

    PROCEDURE: Right shoulder arthroscopy, right posterior labral repair
    with microfracture technique and removal of loose bodies.

    DESCRIPTION OF PROCEDURE: The patient was brought to the operating
    room and placed supine on the operating room table. After induction
    of an interscalene block, he was placed in the beach chair position.
    All bony prominences were padded. His right shoulder was prepped and
    draped in the standard surgical fashion. Posterior portal was
    created. Examination of the joint showed a 1 cm x 1 cm glenoid grade
    IV defect in the surface of the glenoid. There were 2 fissures within
    the humeral head. The subscapularis tendon was intact. Biceps tendon
    was of a normal caliber. The insertion site showed normal attachment
    anteriorly. Posteriorly though, there was a posterior labral tear.
    There was a normal sublabral foramen anteriorly. Anterior inferior
    labrum was intact. The supraspinatus was intact. There was no
    Hill-Sachs defect seen posteriorly. There were loose bodies of
    glenoid articular surface in the axillary pouch. The labrum was
    frayed posteriorly. The labrum was debrided posteriorly and a
    superior labral repair was carried out with 3.0 Bio-SutureTak. The
    3.5 mm full radius shaver was used to remove the loose bodies within
    the articular cartilage. Attention was directed towards the glenoid,
    where the microfracture awls were used to perform the microfracture
    technique on the grade IV surface. The shoulder was irrigated. The
    portals were closed with 4-0 nylon. A dry sterile dressing was
    applied. The patient tolerated the procedure well and returned to
    recovery in stable condition.

    As always - really appreciative!!!!


  2. Default Shoulder surgery with microfracture technique
    Does anyone have any ideas for this one? I am desperate need of help!!

    Thank you in advance.


  3. #3
    Quote Originally Posted by Desperate Denise View Post
    Does anyone have any ideas for this one? I am desperate need of help!!

    Thank you in advance.

    why did you choose 29806 over 29807?
    Mary, CPC, CANPC, COSC

  4. Default Shoulder case
    Mary - thank you for your response.

    After reviewing the opnote and speaking with the doc, you were right about 29807. The doc wanted to know if there was another code that could be added to this for the microfracture portion.

    Thank you so much again - I truly appreciate your help -

    Very grateful for your time - Denise

  5. #5
    Sorry, did not see this in time. For future reference, for the Microfracture, I was thinking of the unlisted 29999 using the comparative 29879 send in op-report and see if the carrier will pay, but process does hold up reimbursement because it takes time for them to review and decide. Anyone else have any thoughts on this ?

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