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Thread: Procedure coding help

  1. #1

    Default Procedure coding help

    AAPC: Back to School
    I'm new to ortho coding. Could someone help me out with what CPTs to use for this OP note? Thanks.

    PREOPERATIVE DIAGNOSES: Right shoulder biceps tendinosis, SLAP tear, partial tear at the supraspinatus, subacromial impingement.

    POSTOPERATIVE DIAGNOSES: Right shoulder biceps tendinosis, SLAP tear, partial tear at the supraspinatus, subacromial impingement.

    PROCEDURE PERFORMED: Right shoulder arthroscopy, biceps tenotomy, debridement
    of SLAP lesion, identification a partial supraspinatus tear, subacromial decompression, articular surface debridement of supraspinatus tear.

    DESCRIPTION OF PROCEDURE: Patient was taken to the operating room after
    interscalene block was obtained. He was placed in the supine position and placed under general endotracheal anesthesia. He was then placed in left lateral decubitus position and appropriately padded. Fourteen pounds of traction were placed on the right arm with forward flexion and abduction. Standard posterior arthroscopy portal was then established. The joint was surveyed. Anterior portals were then established just underneath the biceps tendon. The labrum was noted to have a small tear anteriorly which was gently debrided. This superior labrum was frayed and torn. It was a type 2 tear. The biceps was very inflamed and irritated intraarticularly. Biceps tenotomy was
    then performed with the electrocautery. The articular surfaces were noted to be slightly worn on the glenoid and the humerus. A small rotator cuff tear was identified on the articular surface near the supraspinatus tendon. A spinal needle was then placed through the tear and a Prolene suture was threaded through this. The scope was then directed into the subacromial space. Subacromial spur was identified. Soft tissue was removed with a shaver and electrocautery. Subacromial block decompression was then performed using the bur. The bursa was then debrided with a shaver and the area where the suture
    had been placed from the articular side was identified after the bursa was removed. This tear was not noted to be full-thickness. There was no significant opening. The suture was then removed and the remainder of the rotator cuff was inspected and noted to be intact.

  2. #2


    Start with 29823 and check out 29826, 27 and 29999. If you have a Coders' Desk Reference, let your doctor know he debrided the SLAP tear and didn't repair it. That's an argument I've been through!
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

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