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Partial Tear Bursal-sided

  1. Question Partial Tear Bursal-sided
    Medical Coding Books
    I have an operative report on which the surgeon wants to use 29827 29826 29824 29821

    1. Arthroscopy right shoulder with subacromial decompression
    2. Arthroscopy right shoulder with synovectomy
    3. Arthroscopy right shoulder with debridement of rotator cuff

    Standard poterior portal was established. The arthroscope was placed into the glenohumeral joint, the glenohumeral joint was visualized. Systematic examination of the glenohumeral joint revealed the following. Hypertrophic synovitis was present. Labral fraying was present. No SLAP tear was present. There was no laberal tearing anteriorly. The subscapularis was slighly abnormal. Middle glenohumeral ligament was normal. Posterior labrum demonstrated fraying with grade 1 chondromalacia. Using a spinal needle in the outside-in technique, an anterior rotator interval portal was created. Using a 4.5 synovial resector, synovectomy and debridement of labral fraying was performed. The undersurface rotator cuff demonstrated no articular sided tearing. At this point all arthroscopic intrumentation was removed from the shoulder. The arm was adducted slightly. The subacromial space as entered bluntly using a spinal needle in an outside-in technique, a lateral working protal was created. Bleeding bursitis, and subacromial inflammation was noted. Using a 5.5 synovial resector and a 3.5 90 degree ArthroCare wand, complete subacromial bursectomy was carried out. There was edvidence of piro deltoid take down and acromioplasty. Thre was a small anterior acromial osteophyte. Using a 5.5mm barrel burr, anterior acromioplaty was performed smoothing the acromion back ot the posterior margin of the AC joint. Light debridement of the undersurface of the distal clavicle was undertaken as well. There was minimal bursal sided tearing of the rotator cuff and this was debrided.

    The use of 29827 and 29824 just don't sound right.
    The office follows NCCI not AAOS guidelines though I tend to think using the strictor rules is the safer way to go.
    Last edited by; 02-17-2012 at 12:20 PM. Reason: typos

  2. Default
    I figured out the answer to my question. Thank you

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