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Shoulder coding help

  1. Default Shoulder coding help
    Medical Coding Books
    Good morning group,

    I have an OP report where the doc wants to code 29827, 29826, 23410, 23412, and 23430.

    His Dx codes are 727.61, 726.19, 726.12.

    Here is the OP note:

    "The patient identified in the holding area. Preoperative evaluation was found to be unchanged and that was documented in my office chart. Risks and benefits were explained. He was brought back to the operating room and placed supine on the operating room table. Anesthesia was administered. He was positioned in a beachchair position, properly padded, prepped and draped. A #15 blade was used to make a posterior portal incision. The glenohumeral joint was entered. An anterior portal was established. The debridement was performed. I debrided the subscapularis and supraspinatus tendon as well as biceps tendon. I used Allis to debride and enter tubercle portion of the biceps to the intraarticular position and I identified severe fraying. It appeared that this portion of tendon was adherent to the groove already. I released the tendon from the superiorly to the tubercle. I debrided the partial rotator cuff tear. I then went subacromial space to the lateral portal and performed a bursectomy. I then identified the calcium deposit by placing a spinal needle fluid. Once it was identified, I scooped it out. Down there, there was a bursal-sided tear once it was removed. I want to see if this bursal-sided tear corresponded with articular-sided tear that I noticed previously, so I went and placed the acromion through this tear into the intraarticular region. I went back into glenohumeral joint and found that was in exact same location. I then therefore went back in the subacromial space burred down the tuberosity right at the area of the tear and then placed a single 5.5 Helix anchor and this was then entered, sutures were then passed with an ExpresSew suture settling device. At this time, the rotator cuff beautifully back into place. I then removed the remaining soft tissue undersurface of the acromion, I then performed a standard arthroscopic modification Rockwood 2-step acromioplasty, first removing the anterior edge followed by cutting block technique from posterior to anterior. When I was satisfied, a drained the shoulder of all arthroscopic fluid, removed the debris I can find, followed by closure of the skin. I then went ahead and drained the shoulder. Re-prepped and draped the shoulder and then made a delta pectoralis incision. Meticulous hemostasis was achieved, identified the bicipital groove and made a small incision, after I went down to the delta pectoral interval, identified the bicipital groove and removed some additional bursa that overlying the groove, made a small incision and then delivered the biceps out of the wound. I excised the abnormal area, placed an anchor in the bicipital groove and then sewed the tendon back to the groove with a running locking stitch. I then tied into place. I then used the same sutures and passed then in a retrograde fashion around the subscapularis reinforcing the subscapularis. I copiously irrigated, I used 0-Vicryl to close the fascia, deep followed by subcutaneous and skin closure. The patient had sterile dressing and sling applied. He was awoken from anesthesia and transferred to postanesthesia care unit in stable condition. There are no complications."

    If I am reading this correctly, I believe this should be coded with 29827, 29826, and 23430. I don't think that the documentation supports either code 23410 or 23412.

    Thanks for any thoughts on this.

  2. Default
    I agree with you. I would code 29827,29826,23430. That's it.

  3. #3
    Default Me to
    I agree as well for what it's worth

  4. Default Shoulder case
    I agree - I had a similar case and contacted the AAOS and the results were the same. My docs op-note was similar as well.

    Hope that helps.


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