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Shoulder Audit

  1. Default Shoulder Audit
    Medical Coding Books
    Blue Shield sent a note stating that I cannot submit the arthroscopic subacromial decompression with the mini-open rotator cuff repair - I was under the impression that you could - they are saying it is incidental.

    Any input will be appreciated:

    Thank you in advance for any comments.

    POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff repair.

    PROCEDURE: Right shoulder arthroscopy, subacromial debridement, mini
    open rotator cuff repair, and insertion of anesthetic catheter.

    INDICATIONS: The patient is a 52-year-old with complaints of pain in
    her right shoulder. Risks and benefits of surgery were discussed with
    the patient including bleeding, infection, nerve or artery damage,
    failure to improve her pain, need for further surgery, and she wished
    to proceed.

    DESCRIPTION OF PROCEDURE: The patient was brought to the operating
    room and placed supine on the operating room table. After induction
    of interscalene block, she was placed in the beach chair position.
    All bony prominences were padded. Her right shoulder was prepped and
    draped in the standard surgical fashion. A posterior portal was
    created. Examination of the joint showed a normal subscapularis
    tendon. There was a tear of the supraspinatus, split anteriorly over
    the biceps, extending posteriorly into the infraspinatus. The
    infraspinatus and teres minor were intact posteriorly. The biceps
    anchor and the labrum were intact. Attention was directed to the
    subacromial space where this was confirmed after debriding the tissue.
    The mini open incision was chosen. Dissection was carried down
    through skin and subcutaneous tissue. The rotator cuff was identified
    and the edges were debrided. The greater tuberosity was debrided.
    The #2 FiberWire was used to close the rotator interval anteriorly
    covering the biceps tendon. A 5.5 peak anchor was placed into the
    greater tuberosity and the rotator cuff tendon was brought back to the
    tuberosity posteriorly. The humeral head was covered at the
    conclusion of the case. The shoulder was irrigated and the pain pump
    catheter was inserted at this point.

  2. Default Mini-Opens
    A scope subacromial decompression with mini-open codes to 23412. The Scope SAD is bundled into Mini.

  3. #3
    Default Shoulder Audit
    The body of the op-report only mentions "Debridement 29822" it does not mention "Decompression of the distal clavical in the subacromial space 29826"

    "The biceps anchor and the labrum were intact. Attention was directed to the
    subacromial space where this was confirmed after debriding the tissue".

    Are you getting the two confused?

  4. Default Yoli and Jacabullis
    Thank you for your help - sometimes I get confused with his op-notes because he generalizes and is vague. I need to have him be more specific in his op-notes.

    Thanks again for all your help!!


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