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shoulder coding help

  1. #1
    Default shoulder coding help
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    hello! I am having difficulty with a complicated shoulder surgery and am desperately seeking any help available. My doc codes himself and I then "re-code". Normally, we agree, I'm just not on board with him on this surgery and need other opinion/advice. I have abbreviated to help condense the OP report.
    (Dr. codes: 23430, 29807, 29826, 23420).
    THANK YOU!!!!!!!!!

    Diag arth camera into glenohumeral space, arth carried out with findings: 1) anterior glenoid labral tear, 2) bicep tendon tear, 3) complete disruption supraspinatus tear. Arth shaver introduced into anterior portal and arth debridement of bicep tendon was carried out. Synovectomy was carried out in the glenohumeral joint. Anterior glenoid labral reconstruction was carried out utilizing a Juggernaut suture anchor with a Tennessee slider knot. Arth photos were taken throughout the glenohumeral portion of the proc to confirm both dx and completion of proc. Arth camera was reintroduced into the subacromial space, a large anterior acromial spur was identified. No appreciable inferior osteophytes. The acromioclabicular joint was identified. Arth barrel bur was intermittently intro into the lateral arth portal and arth subacromial decompression was carried out. The lateral portal was extended in a proximal direction. Deltoid splitting subacromial approach was carried out to the subaromial space. Full thickness glenoid labral tear was sharply debrided. A bleeding bony trough was created in the proximal aspect of the left humerus in the area of the greater tuberosity of the left humerus. Open exploration of the bicipital tuberosity failed to reveal the inferior end of the long head of the biceps tendon. A second small inc was created over the anterior aspect of the proximal left humerus in the area of the deltopectoral fascia. The long head of the biceps was found. No appeciable repairable tendon was attached to the biceps tendon indicating a rupture at the musculotendinous junction. Given the non-repairable aspect of the biceps tendon rupture, the wound was copiously irrigated in the area of the anterior left humerus. Fascia was reapproximated. Rotator cuff repair was carried out utilizing 2 ALLthread 5.5mm PEEK suture anchors medially and two 5.5mm PEEK ALLthread suture anchors laterally in double row rotator cuff repair technique. The shoulder was taken thru a passive range of motion and found to be stable without impingement of the repair upon the subacromial space. The wound was copiously irrigated. Deep and superficial fascia of the deltoid musculature was reapp.

  2. #2
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    Quote Originally Posted by shellip View Post
    hello! I am having difficulty with a complicated shoulder surgery and am desperately seeking any help available. My doc codes himself and I then "re-code". Normally, we agree, I'm just not on board with him on this surgery and need other opinion/advice. I have abbreviated to help condense the OP report.
    (Dr. codes: 23430, 29807, 29826, 23420).
    THANK YOU!!!!!!!!!

    Diag arth camera into glenohumeral space, arth carried out with findings: 1) anterior glenoid labral tear, 2) bicep tendon tear, 3) complete disruption supraspinatus tear. Arth shaver introduced into anterior portal and arth debridement of bicep tendon was carried out. Synovectomy was carried out in the glenohumeral joint. Anterior glenoid labral reconstruction was carried out utilizing a Juggernaut suture anchor with a Tennessee slider knot. Arth photos were taken throughout the glenohumeral portion of the proc to confirm both dx and completion of proc. Arth camera was reintroduced into the subacromial space, a large anterior acromial spur was identified. No appreciable inferior osteophytes. The acromioclabicular joint was identified. Arth barrel bur was intermittently intro into the lateral arth portal and arth subacromial decompression was carried out. The lateral portal was extended in a proximal direction. Deltoid splitting subacromial approach was carried out to the subaromial space. Full thickness glenoid labral tear was sharply debrided. A bleeding bony trough was created in the proximal aspect of the left humerus in the area of the greater tuberosity of the left humerus. Open exploration of the bicipital tuberosity failed to reveal the inferior end of the long head of the biceps tendon. A second small inc was created over the anterior aspect of the proximal left humerus in the area of the deltopectoral fascia. The long head of the biceps was found. No appeciable repairable tendon was attached to the biceps tendon indicating a rupture at the musculotendinous junction. Given the non-repairable aspect of the biceps tendon rupture, the wound was copiously irrigated in the area of the anterior left humerus. Fascia was reapproximated. Rotator cuff repair was carried out utilizing 2 ALLthread 5.5mm PEEK suture anchors medially and two 5.5mm PEEK ALLthread suture anchors laterally in double row rotator cuff repair technique. The shoulder was taken thru a passive range of motion and found to be stable without impingement of the repair upon the subacromial space. The wound was copiously irrigated. Deep and superficial fascia of the deltoid musculature was reapp.
    I don't see documentation of a SLAP tear (maybe 29806 rather than 29807). I see 23410-12 for open RC repair not reconstruction (23420). Biceps rupture was not repaired so I don't see how you could capture 23430. So I see 23412, 29826 and maybe 29806. But I would double-check with him. Anyone else?

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