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  1. #1
    North Carolina
    Default Rotator Cuff Tear - PREOPERATIVE DIAGNOSIS
    Medical Coding Books
    PREOPERATIVE DIAGNOSIS: Rotator cuff tear, right shoulder.

    POSTOPERATIVE DIAGNOSES: Rotator cuff tear, right shoulder;
    osteoarthritis, right glenohumeral joint; osteoarthritis, distal clavicle with large subacromioclavicular spurring; full-thickness rotator cuff tear.

    PROCEDURES: Arthroscopy, right shoulder, with debridement of
    arthritic glenohumeral joint; Mumford; subacromial decompression with rotator cuff repair using Arthrex Bio SwiveLock suture ankle times 2.

    INDICATIONS FOR PROCEDURE: This 78-year-old right hand
    dominant female had injured her right shoulder in a fall several weeks ago in which she had also sustained a metacarpal fracture. The metacarpal fracture has healed, but she continues to have significant pain in the right shoulder. She had had previous open right shoulder surgery many years ago, the specifics of which were unclear based on her report. An MRI scan demonstrated a full-thickness rotator cuff tear, but there did not appear to be significant glenohumeral arthropathy. It was felt that arthroscopic evaluation and treatment of her right shoulder condition was indicated.

    DESCRIPTION OF PROCEDURE: After a right scalene block was
    induced and an interscalene catheter was left for postoperative pain control, the patient was taken to the operating room and placed on the operating table in the supine position. After undergoing successful general anesthetic and endotracheal intubation, she was placed in the beach chair position with her head and neck well supported with posterior padding, as well as restraints anteriorly. The irrigant contained epinephrine per standard protocol, and the arthroscopic pump was used at 60 mmHg. The arthroscope was introduced through a posterior portal, and the glenohumeral joint was scanned with the following findings:

    There was significant glenohumeral arthritis, with a large glenoid osteophyte in the 11 o'clock position. The subscapularis appeared to be chronically torn, and there was no evidence of the biceps tendon. There was a large tear of the anterior portion of the supraspinatus, but the infraspinatus tendon appeared to be intact. An anterior portal was created, going through the rotator cuff defect. Debridement of the glenohumeral joint including the large glenoid osteophyte at the 11 o'clock position was performed with punch, bur, and shaver. Shaver and electrocautery were used to debride synovitis. I then redirected the scope in the anterior portal into the subacromial space, and subacromial decompression was performed removing previous scar tissue and bursitic tissue. It was noted that there was a large subclavicular spur at the acromioclavicular joint. This was skeletonized and Mumford procedure was performed using standard technique, removing the subclavicular spur, as well as approximately 1 cm of distal clavicle. I then tested the mobility of the rotator cuff tear by creating another portal in the anterior superolateral area. The cuff was quite mobile, and although she did appear to have a subscapularis tear, I thought it was worthwhile trying to repair the supraspinatus tear to see if this along with decompression gave her any improvement in function. The subscapularis stump was debrided, and using the Arthrex SwiveLock system, I initially placed three #2 FiberWire suture tapes from front to back. I was _____ to incorporate the most posterior of the tapes in a SwiveLock system with excellent purchase. However, when I attempted to do a similar anchoring of the middle suture, the quality of the bone was such that it would not hold the SwiveLock. I therefore removed this tape, and I was able to stabilize the anterior suture tape to another SwiveLock placed more anteriorly. After the rotator cuff repair, it was assessed. There appeared to be good repair of the supraspinatus tendon with excellent coverage of the humeral head.The shoulder was then irrigated and aspirated. The arthroscopic instruments were removed. The portals were closed with skin staples. Sterile dressing and sling were applied.

    TIA for your thoughts~
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

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  2. #2
    29827, 29826, 29824, 29822

    with appropriate modifiers of course

  3. #3
    oh and who did the interscalene block, the surgeon or anesthesiologist?

    If it was the surgeon (thats who you are coding for), you would also code 64418.

  4. #4
    North Carolina


    I just want to say...You are so, so helpful and very knowledgeable. KUDOS TO YOU!!!!
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

  5. Unhappy
    What would the DX code be for full thickness rotator cuff defect involving the entirety of the supraspinatus component of the cuff?

  6. Default
    Quote Originally Posted by View Post
    What would the DX code be for full thickness rotator cuff defect involving the entirety of the supraspinatus component of the cuff?
    here are the chronic and acute codes.

    RTC Tear ICD-9

    727.61 (non-traumatic complete rupture of rotator cuff), full thickness
    726.10 (disorder shoulder tendon cuff)
    840.3 (sprain and strain: infraspinatus)
    840.4 (sprain and strain: rotator cuff)
    840.5 (sprain and strain: subscapularis)
    840.6 (sprain and strain: supraspinatus)
    726.13 Partial tear of rotator cuff

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