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Shoulder coding

  1. Default Shoulder coding
    Clearnace Sale
    I really need your help with this - -

    I must have missed something at the last coding course I went to cuz the insurance carriers are killing me with inquiries and takebacks on my shoulders.

    I get hung up on the back to front thing with the 29823 code and then deciding when I can bill the 29826 with 29822 or 29823 - I am fearful of unbundling. Then the modifier 59 vs 51 - I need a meeting desperately.



    Here is the op-note:

    PREOPERATIVE DIAGNOSIS: Left shoulder labral tear.

    1. Left shoulder labral tear.
    2. Rotator cuff tear.
    3. Impingement syndrome.

    OPERATION PERFORMED: Left shoulder arthroscopy. Rotator cuff debridement.
    Labral debridement. Arthroscopic bursectomy with subacromial

    INDICATIONS FOR PROCEDURE:The patient is a 36 year old who has pain in
    his left shoulder who has failed conservative measures. The risks and
    benefits of the surgery were discussed with the patient including
    bleeding, infection, nerve or artery damage, failure to improve his pain,
    need for further surgery, and he wishes to proceed.

    DESCRIPTION OF PROCEDURE:The patient was brought to the operating room and placed supine on the operating room table. After induction of general anesthetic and an interscalene block, he was placed in the beach chair position. All bony prominences were padded. His left shoulder was
    prepped and draped in a standard surgical fashion. An inferolateral
    portal was created. The examination of the joint showed normal
    subscapularis tendon, normal glenohumeral articular surfaces. There was a
    type 1 tear of the superior labrum. The biceps tendon was intact. There
    was a 10% tear of the supraspinatus. There was 3 mm of greater tuberosity

    The 3.5 mm full radius shaver was used to perform a rotator cuff
    debridement and a labral debridement. The posterior labrum was intact.
    The inferior capsule was intact. The attention was then directed to the
    subacromial space where a subacromial decompression was carried out.
    There was a significant spur anteriorly. The rotator cuff was intact from
    above. The shoulder was irrigated, and the portals were closed with 4-0

  2. #2
    The Description of Procedure is short on details. The surgeon needs to tell you where he/she was when doing the debridement in order to determine if you use 29822 or 29823 with 29826.

  3. #3
    Default shoulder debridement
    try the above link, it gives you all the information you need to know about 29823, 29822 and 29826
    i hope this helps....
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

  4. Default Shoulder coding
    Thanks coderguy and astephens for your help with the shoulder stuff.

    It has been difficult for the past 10 years to get this doc to document the details. He doesn't get it. He's a great guy but . . .

    Thanks so much

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