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Thread: Shoulder surgery help please!!!

  1. #1

    Default Shoulder surgery help please!!!

    AAPC: Back to School
    I am really having a hard time with shoulder surgery coding - please help.

    My question once again is about arthroscopic shoulder procedures performed with open shoulder procedures. In this case the physician performed arthroscopically a repair of a complex labral tear and an extensive debridement of the glenohumeral joint. Then he performs an open biceps tenodesis. Please let me know what you guys think.

    1. Right shoulder pain.
    2. Right shoulder instability.
    3. Right shoulder anterior labral tear.
    4. Right shoulder complex type IV superior labrum anterior and
    posterior lesion.

    1. Right shoulder arthroscopy.
    2. Right shoulder anterior labral repair.
    3. Right shoulder biceps tenodesis.
    4. Right shoulder extensive debridement of glenohumeral joint.

    The bony landmarks of the shoulder, including posterior
    lateral, lateral and anterior lateral aspects of the acromion, were marked
    with a marking pen. The AC joint and coracoid process were marked with a
    marking pen. The mark was made 2 fingerbreadths down, 2 fingerbreadths
    medial from the posterior and lateral aspect of the acromion. An 18 gauge
    spinal needle was inserted into the glenohumeral joint. The joint was
    distended with 60 mL of sterile saline. An 11 blade scalpel was used to
    incise the skin. The arthroscope was introduced into the glenohumeral
    joint, and the diagnostic arthroscopy was begun. There was evidence of
    grade I-II chondromalacial changes over the humeral head, minimal
    chondromalacial changes over the glenoid surface. There was evidence of
    an anterior labral tear with a bony Bankart. There was evidence of a type
    IV SLAP lesion. There was no evidence of a rotator cuff tendon tearing.
    No evidence of loose bodies within the axillary pouch. An anterior portal
    was established using an outside-in technique. An 18 gauge spinal needle
    was inserted above the superior border of the subscapularis muscle. An 11
    blade scalpel was used to incise the skin. A 7.0 cannula from Arthrex was
    introduced into the glenohumeral joint. The labrum was felt to be
    unstable and of poor tissue quality and unrepairable. The superior labrum
    was debrided. The biceps tendon had partial tearing along its root. The
    biceps tendon was tenotomized. Attention was then turned to the anterior
    labrum. The small bony Bankart piece was removed. The anterior neck of
    the glenoid was cleared of all soft tissue and decorticated using a 4.0
    acromionizer bur. The anterior labrum was mobilized using a periosteal
    elevator. Then 4 Griffin anchors were placed on the anterior face of the
    glenoid, and these were then passed using a 45 degree suture lasso to the
    right. These were tied in a sequential fashion starting from anterior-
    inferior to anterior-superior. Once the labral repair was complete,
    arthroscopic probe was used to probe the repair and it was felt to be
    stable. All the labral repair was complete, all arthroscopic
    instrumentation was removed from the shoulder. A 3 cm incision was made
    over the anterior lateral aspect of the shoulder. The raphe between the
    anterior and medial heads of the deltoid was identified. Blunt dissection
    was carried down to identify the intertubercular groove. The sheath
    overlying the intertubercular groove was incised with electrocautery.
    Biceps tendon was exposed. A single 5.5 Healix anchor was placed in the
    intertubercular groove after it was decorticated. The limbs of the 5.5
    Healix anchor were threaded in a locking stitch configuration to the
    biceps tendon. The biceps tendon was secured within the intertubercular
    groove. Copious irrigation was performed. The sheath overlying the
    intertubercular groove was closed with 2-0 Vicryl in an interrupted
    fashion. Deltoid fascia was closed with 2-0 Vicryl in an interrupted

    Thank you guys in advance - I don't know what I would do without you!!!


  2. #2


    I think I would code this as
    29807, 23430, 29823.

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