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unsure of shoulder coding

  1. #1
    Default unsure of shoulder coding
    Medical Coding Books
    The anterior superior labral complex and biceps tendon was noted to be significantly deteriorated and frayed, and a significant SLAP lesion of the superior labral complex was noted. Due to biceps tendinopathy and the patient's age, it was elected to do a biceps tenodesis, and the biceps was then cut at the level of the superior labral area, and for the moment left alone.

    In the superior aspect of the shoulder, a complete rotator cuff tear, from the anterior aspect of the supraspinatus posteriorly to the infraspinatus interval was completely torn, with significant retraction of about 1.5 to 2 cm in an elliptical fashion. The edge of the tendon appeared to be in pretty good shape, however. This was débrided from the intraarticular aspect. The subacromial space was then entered. At that time, a bursectomy was completed for visualization of the cuff tear and the coracoacromial ligament, which was then resected and removed off the undersurface of the acromion and the anterior aspect of the acromial edge.

    At that point, the decompression was completed using a 5.5 mm burr through a lateral incision, removing the undersurface of the acromion about 6 to 7 mm, and anteriorly as well, beveling it back. This decompressed the subacromial space well. The AC joint was uncovered anteriorly, found to be intact, and was left alone.

    At that point, the scope was then converted to an open procedure. A 2-inch incision was then made in line with the lateral incision and carried to the anterolateral tip of the acromion. The self-retaining retractor was then placed underneath the deltoid, exposing the subacromial space and subdeltoid area. The complete rotator cuff tear could be visualized at that point from the rotator cuff interval posteriorly to the insertional area of the infraspinatus tendon. Tendon retraction was approximately 1.5 to 2 cm. The tendon could be mobilized, however, to its anatomic position. At the insertion area, a burr was then used to decorticate the area about 6 to 7 mm in width and across the insertional area of the tendon. The biceps tendon was then tagged and brought out of the way for the time being.

    In the trough insertion area, two 5.5 suture anchors with fiber tape were then placed and the fiber tape was then brought in from the inferior surface of the tendon and out the superior surface of the tendon about 1 cm from its margin. An additional fiber wire #2 suture was then used to tenodese the biceps tendon over the repair area. The four limbs of suture, along with the tenodesis of the biceps tendon were then brought across the decorticated area, reducing the cuff nicely into that area, and then were anchored into a lateral row of anchors using the same type suture anchor. These were then driven into the bone, reducing the cuff tear nicely. All sutures were then cut at that point, after knots were tied. The arm was taken through a full range of motion, with minimal tension on the repair.


    Could someone let me know if I am on the right tract?

  2. #2
    We use 29807 if it is a true SLAP tear. 29806 is mostly used for labral repairs.
    I agree with the 29826 for the decompression. Since the note states a complete tear for the rotator cuff I'd use 23420 for a full tear. I'd also use 2420 for an open bicep tenodesis. Hope this helps.

  3. #3
    what for the tendonesis? 23430? but isnt that included in the cuff repair??

  4. Default
    To me your operative note reads as if the r/c repair was done arthroscopically, as well as the decompression, then the surgery was converted to open....23420 is an open r/c repair, 29827 is arthroscopic. I would agree with the 23430 for the open biceps tenodesis.

  5. #5
    To me, the note reads that after the decompression, it was converted to an open procedure for the rotator cuff repair so would be billed as open RCR.

  6. #6
    I got the open but my question is the tendonesis included in the open. can I bill for the tendonesis???

  7. #7
    Sorry. Looks to me like 29826, 23430, & either 23412 or 23420. AAOS does not consider the open tenodesis included with either of the rotator cuff repair codes. However, CCI considers 23430 as included with 23420. It does not consider it included with 23412, however. In reading the op note, it kind of sounds like the tenodesis was used as part of the rotator cuff repair??? But I guess you could still bill 23412 and 23430 even if the tenodesis was helping to fix the rotator cuff? This is getting wordy, sorry. Also, I don't see in the op note where you could bill a 29807 - after he talks about there being a SLAP tear, he decides to do a tenodesis. I don't see a SLAP repair, but could be wrong. What procedures did he list as procedures performed?

  8. #8
    right shoulder arthroscopy
    subacromial decompression
    mini open rotator cuff
    biceps tenodesis

    and thanks for your time and opinions you are a great help

  9. #9
    You're welcome, and just so we're on the same page: Okay, so he did NOT do a SLAP repair, so you would not bill 29807 or 29806. I would only bill 29826, 23412 vs 23420 & 23430 (& previous notes).

  10. #10
    I dont know why I thought he did the slap..... thank you again for your opinion I agree. sometimes you just need extra eyes!!!

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