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Shoulder coding opinion

  1. Question Shoulder coding opinion
    Medical Coding Books
    Hi all !

    I have a Doc who wants to use 29806 and 29807-59, but I don't think the OP report supports 29806. OP note follows. Thanks for any advice. You guys are the best!!!

    PREOPERATIVE DIAGNOSES: 1. Left shoulder posterior and superior instability, superior glenoid labrum tear.

    2. Posterior Bankart.

    POSTOPERATIVE DIAGNOSES: 1. Left shoulder posterior and superior instability, superior glenoid labrum tear.

    2. Posterior Bankart.

    PROCEDURE PERFORMED: 1. Left shoulder arthroscopic posterior Bankart reconstruction.

    2. Arthroscopic superior glenoid labrum repair (SLAP.)


    PROCEDURE IN DETAIL: After induction of anesthesia and administration of IV antibiotics, surgical pause was conducted. The patient was examined and seemed to have a posterior load and shift, which was asymmetrical with contralateral side with an associated quick. He was in the room in lateral decubitus position. All bony prominences well padded. The left arm was prepped, draped, and placed in the arthroscopic arm holder. Standard posterolateral and arthroscopy portals were established. Diagnostic arthroscopy ensued. This showed a large posterior glenoid labrum tear extending all the way up to the posterior aspect of the biceps complex. The subscapularis, supraspinatus, and infraspinatus tendons were all intact. I then created anterosuperior and anterior working portals. I began looking from the anterosuperior. Again by looking superiorly, I debrided the glenoid articular margin and then repaired the superior glenoid labrum. There were two suture anchors composed of peak material with FiberWire suture. I then switched from anterosuperior. I debrided the glenoid articular margin posterior and posteroinferiorly and then imbricated the posterior Bankart and imbricating some capsule with a spectrum suture passer, shuttling Prolene through and then securing down the posterior labrum with peak suture tacks with #2 FiberWire. At the conclusion of case, all debris, fluid, and instruments were removed. I then entered from the joint and I then entered the subacromial space. There was no real bursitis and I did no further surgery. The portals were closed with subcuticular sutures and Steri-Strips. The patient was placed in a sling and soft dressing and returned to the recovery room.

  2. #2
    Location
    Milwaukee and Madison
    Posts
    6
    Default
    This op report does not justify the use of cpt 29806

  3. #3
    Location
    South Bend
    Posts
    23
    Default
    This showed a large posterior glenoid labrum tear extending all the way up to the posterior aspect of the biceps complex. The subscapularis, supraspinatus, and infraspinatus tendons were all intact. I then created anterosuperior and anterior working portals. I began looking from the anterosuperior. Again by looking superiorly, I debrided the glenoid articular margin and then repaired the superior glenoid labrum. There were two suture anchors composed of peak material with FiberWire suture.

    I believe this is the 29807

    I debrided the glenoid articular margin posterior and posteroinferiorly and then imbricated the posterior Bankart and imbricating some capsule with a spectrum suture passer, shuttling Prolene through and then securing down the posterior labrum with peak suture tacks with #2 FiberWire.

    I believe this is the 29806

    I didn't look in CCI for edits.

    Just my opinion,

    Sandy Goodknight, CPC, CPMA, CEMC

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