There is a physician in the practice who dictates minimally. I am having a very difficult time coding his shoulder op notes.

For instance, the diagnoses noted were: distal clavicle fx, impingement syndrome and rotator cuff tear. The physician reports ..."there was a small bursal sided fraying of the rotator cuff that was debrided', a distal clavicle excision was carried out with an acromionizer", attention was directed to the subacromial space where a subacromial decompression was carried out".

I have a hard time with this - there is no indication how much was excised on the clavicle, the subacromial decompression was just "carried out". Can I bill for the subacromial decomrpession? Doesn't he have to dictate more than just the words? Can I bill 29826, 29822 and 29824???

The second instance: patient's diagnoses are rotator cuff tear and impingement syndrome. The physician reported, "the supraspinatus had a full thickness tear which was debrided, the subscapularis had some partial tearing which was debrided, the greater tuberosity was debrided intra-articularly. The biceps tendon was significantly frayed and a biceps tenotomy (arthroscopic) was performed. Attention was then directed to the subacromial space where a subacomial decompression was performed. Two 5.5 Biocomposite anchors were placed in the greater tuberosity and two horizontal sutures were passed throught the rotator cuff and tied down. Two 4.5 pusholock anchors were placed laterally...." So how would anyone code this . . . 29827 for rotator cuff repair, 29823-59 (not sure about modifier of code) for the debridements, 29999 for the arthroscopic biceps tenotomy. Not sure if I can bill for the subacromial decompression because he just says it was "carried out".

Any help will be greatly appreciated!!!

Does anyone know of a good coding course focusing on the shoulder that might be coming up??

Thank you in advance - Denise