AAPC - Back to school
Results 1 to 3 of 3

Thread: Multiple shoulder procedures - Patient is a 60-year-old female

  1. #1

    Default Multiple shoulder procedures - Patient is a 60-year-old female

    AAPC: Back to School
    This is a beauty - I would greatly appreciate all the help I can get!!!!

    I checked the CCI edits and came up with 29827, 29826-51, 29825-51, 29999 biceps tenotomy (should there be a modifier)


    1. Left shoulder adhesive capsulitis.
    2. Rotator cuff tear.
    3. Type 1 labral tear.
    4. Biceps tear.

    1. Left shoulder arthroscopy.
    2. Arthroscopic rotator cuff repair.
    3. Capsular release.
    4. Subacromial decompression.
    5. Debridement of type 1 labral tear.
    6. Excision of os acromiale.
    7. Biceps tenotomy.

    INDICATIONS FOR PROCEDURE: Patient is a 60-year-old female with
    complaints of left shoulder pain who has failed conservative measures.
    She has had difficulty with loss of motion and pain with motion. The
    risks and benefits of surgery were discussed with the patient including
    bleeding, infection, nerve or artery damage, failure to improve her pain,
    need for further surgery, and she wished to proceed.

    DESCRIPTION OF PROCEDURE: Patient was brought to the operating room and
    placed supine on the operating table. After induction of general
    anesthetic and interscalene block, she was placed in the beach chair
    position. All bony prominences were padded. Her left shoulder was
    prepped and draped in the standard surgical fashion. A posterior portal
    was created. Examination of the joint showed normal glenohumeral
    articular surfaces. The subscapularis tendon was intact. There was a
    thick adhesive capsulitis that was seen, which was taken down with a
    capsular release with a TurboVac wand. The biceps had significant fraying
    and was smoothed. After smoothing of the biceps, it was noted to have an
    80% tear in its mid substance. A tenotomy was carried out. Attention was
    directed to the rotator cuff, where the supraspinatus insertion was
    intact. The infraspinatus insertion was intact. The teres minor was

    Attention was directed to the subacromial space, where a subacromial
    decompression was carried out after a bursectomy. There was a large, 90%,
    bursal surface tear of the rotator cuff, which was completed with the
    TurboVac wand. There was a spur on the greater tuberosity, which was
    smoothed with an acromionizer. An os acromiale was seen medially and
    anteriorly which was removed with an acromionizer. A portal was created
    anteriorly, and two 5.5 PEEK anchors were placed into the greater
    tuberosity. Two sutures were passed in a horizontal fashion through the
    tendon and tied down. Two 4.5 PushLock anchors were then placed
    laterally, bringing the tendon back to the greater tuberosity nicely,
    covering the tuberosity completely. Intra-articularly, a type 1 labral
    tear was seen superiorly which was debrided with a 4.5-mm full radius
    shaver. :
    Last edited by ank3t; 10-20-2016 at 04:34 AM.

  2. #2


    I would agree with your codes, except for 29825. I've read where a capsular release is considered and extensive debridement and should be coded with 29823.

    Just my 2 cents, hope it's helpful.

  3. #3

    Default Skorkfranks

    Thank you for your help!!!


Similar Threads

  1. Coding Multiple Procedures on Multiple Digits
    By lora.a.cherry@gmail.com in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 01-01-2014, 11:34 AM
  2. Multiple shoulder procedures! Need opinion
    By coder067 in forum Orthopaedics
    Replies: 0
    Last Post: 09-30-2013, 12:36 PM
  3. Multiple shoulder procedures! Need opinion
    By coder067 in forum Orthopaedics
    Replies: 0
    Last Post: 09-30-2013, 10:08 AM
  4. Shoulder Multiple Procedures Help!
    By DStack818 in forum Orthopaedics
    Replies: 0
    Last Post: 11-13-2012, 08:58 AM
  5. Replies: 3
    Last Post: 12-15-2010, 08:14 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.