# Shoulder scope w/paralabral cyst removal



## Deb Jones - CPC (Sep 4, 2012)

THE SURGEON CODES THIS AS 29806, 23430, 29826, AND WANTS TO USE 29999 FOR THE PARALABRAL CYST EXCISION.  SHOULD THE PARALABRAL CYST EXCISION BE BUNDLED INTO 29806 WITH THE SLAP REPAIR INSTEAD OF USING 29999, AND IF SO, SHOULD WE ADD A MODIFIER 22 TO THE 29806 SINCE THIS SEEMS TO BE ABOVE AND BEYOND THE USUAL PROCEDURE BILLED WITH CPT 29806?  THE PAYER IS AETNA FOR THOSE THAT MAY MAKE THAT DISTINCTION IN THEIR CODING; ESPECIALLY SINCE AETNA IS FAMOUS FOR NOT ADHERING TO CCI GUIDELINES.

I KNOW SOME OF YOU LOOK AT THIS AS "FUN" - ENJOY! 
THANK YOU FOR YOUR TIME AND CONSIDERATION, BUT MUST OF ALL YOUR *FEEDBACK*!  
DEB 
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PRE-OP & POST-OP DIAGNOSES:
1 - RIGHT SHOULDER SUPERIOR LABRUM FROM ANTERIOR TO POSTERIOR TEAR
2 - RIGHT SHOULDER LARGE PARALABRAL CYST
3 - RIGHT SHOULDER IMPINGEMENT SYNDROME

PROCEDURES:
1 - RIGHT SHOULDER ARTHROSCOPY WITH RESECTION OF PARALABRAL CYST
2 - RIGHT SHOULDER ARTHROSCOPIC SUPERIOR LABRAL REPAIR
3 - RIGHT SHOULDER ARTHROSCOPICALLY ASSISTED OPEN SUBPECTORAL BICEPS TENODESIS
4 - RIGHT SHOULDER ARTHROSCOPIC SUBACROMIAL DECOMPRESSION

OPERATIVE FINDINGS:
1 - EXAMINATION UNDER ANESTHESIA OF THE RIGHT SHOULDER SHOWED FLEXION 170, ABDUCTION 170, ER 80 AT 90 DEGREES ABDUCTION, ER 90, IR 60, NORMAL STABILITY
2 - GLENOHUMERAL ARTICULAR CARTILAGE INTACT
3 - ANTERIOR INFERIOR LABRUM INTACT. POSTERIOR INFERIOR LABRUM INTACT.
4 - TYPE 2 SLAP TEAR WITH DISPLACEMENT OF THE LABRUM INTO THE JOINT AND INSTABILITY OF THE BICEPS ANCHOR.
5 - SEVERE FRAYING AND THINNING OF THE ANTERIOR SUPERIOR LABRUM WHICH WAS LESS THAN 3mm IN THICKNESS AND HAD LARGE SUBLABRAL FORAMINA.
6 - A LARGE, MULTILOCULATED PARALABRAL CYST OVERLYING THE POSTERIOR GLENOID AND SPINOGLENOID NOTCH WITH CLEAR, VISCOUS, YELLOW CYSTIC FLUID.
7 - SUBACROMIAL SPACE WITH MODERATE BURSITITS.  NO SIGNIFICANT ANTERIOR ACROMIAL SPUR.
8 - BICEPS TENDON WITH MODERATE TENOSYNOVITIS.

AFTER BEING PLACED IN THE PROPER POSITION & RECEIVING ANESTHESIA - PERTINENT POINTS OF THE OPERATIVE PROCEDURE FOLLOW:  A SPINAL NEEDLED WAS USED TO INSUFFLATE THE JOINT WITH 30 mL OF LACTATED RINGER'S. POSTERIOR VIEWING PORTAL WAS ESTABLISHED USING STANDARD TECHNIQUE.  OUTSIDE-IN TECHNIQUE WAS USED TO ESTABLISH AN ANTERIOR ROTATOR INTERVAL PORTAL, AND A 5.0 mm CANNULA WAS INSERTED.  A PROBE WAS INSERTED AND DIAGNOSTIC ARTHROSCOPY COMPLETED WITH THE ABOVE FINDINGS.  NEXT, THE CYST EXCISION WAS PERFORMED.  A TRANS-CUFF PORTAL WAS PLACED MEDIAL TO THE ROTATOR CUFF CABLE BY FIRST LOCALIZING WITH A SPINAL NEEDLE AND THEN USING A SCALPEL TO OPEN THE ROTATOR CUFF MUSCULAR PORTION IN LINE WITH ITS FIBERS USING A SCALPEL.  AN 8 mm CANNULA WAS INSERTED.  INSTRUMENTATION WAS PERFORMED FROM LATERAL WHILE THE ASSISTANT HELD A PROBE FROM ANTERIOR TO ELEVATE AND RETRACT THE ROTATOR CUFF TO ALLOW DISSECTION OF THE CYST.  THE CAPSULE OVERLYING THE SUPERIOR LABRUM WAS OPENED USING A RADIOFREQUENCY PROBE.  BLUNT DISSECTION WAS USED TO CARRY THE INCISION MEDIALLY ALONG TEH GLENOID NECK TAKING CARE TO REORIENT FREQUENTLY TO PREVENT INADVERTENT INJURY TO THE SUPRASCAPULAR NERVE BRANCHES TO THE INFRASPINATUS.  THE INFRASPINATUS WAS ELEVATED AND RETRACTED BY THE ASSISTANT.  THE CYST WAS IDENTIFIED, ADN THE LATERAL WALL WAS RESECTED USING A SHAVER.  THE CYST WAS MULTILOCULATED, AND I MADE MULTIPLE PUNCTURES WITH THE TROCAR FROM THE ARTHROSCOPE TO HELP IDENTIFY ITS EXTENT.  THE CYST WAS COMPLETELY RESECTED USING THE SHAVER AND BLEEDING CONTROLLED WITH RADIOFRQUENCY PROBE.  THE SPINE OF THE SCAPULA WAS REACHED WITH BLUNT DISSECTION, AND THE NERVE FIBERS TO THE INFRASPINATUS WERE IDENTIFIED AND FOUND TO BE INTACT. AFTER THE CYST WAS FULLY EXCISED, THE SUPERIOR LABRAL REPAIR WAS PERFORMED.  THE BICEPS TENDON HAD EXTENSIVE TENOSYNOVITIS, SO IT WAS RELEASED WITHA N ARTHROSCOPIC SCISSOR FOR LATER TENODESIS.  BECAUSE THERE WAS A LARGE POSTERIOR SUPERIOR LABRAL TEAR, A SLAP REPAIR WAS PERFORMED TO PREVENT RECURRENCE OF THE CYST WHICH WAS (THE PATIENT'S) MAIN SOURCE OF SYMPTOMS.  I PLACED A 2.3 mm ANCHOR JUST POSTERIOR TO THE BICEPS. THIS HAD EXCELLENT PURCHASE IN THE BONE.  THE SUSTURE WAS PASSED WITH A SPECTRUM SUTURE PASSER AROUND THE LABRUM AND TIED WITH A KNOT ON THE TISSUE SIDE, REDUCING THE SUPERIOR ASPECT OF THE TEAR.  A SECOND ANCHOR WAS PLACED 1 cm POSTZERIOR TO THE FIRST, AND A SIMILAR TECHNIQUE WAS USED TO TIE THE SUTURE, AGAIN KEEPING THE KNOT ON THE ITSSUE SIDE.  PICTURES WERE TAKEN FROM POSTERIOR AND ANTERIOR TO DOCUMENT THE LABRAL REPAIR WHICH COMPLETELY CLOSED THE SUBLABRAL FORAMEN POSTERIORLY.  NEXT THE INSTRUMENTS WERE REMOVED FROM THE GLENOHUMERAL JOINT AND REPLACED INTO THE SUBACROMIAL SPACE USING BLUNT TROCARS.  A BURSECTOMY WAS PERFORMED REMOVING INFLAMED TISSUE AND EXPOSING THE BURSAL SIDE OF THE ROTATOR CUFF WHICH WAS FOUND TO BE INTACT.  PICTURES WERE TAKEN TO DOCUMENT THE INFLAMMATION WITHIN THE SUBACROMIAL SPACE AND THE INTEGRITY OF THE ROTATOR CUFF.  NEXT, INSTRUMENTS WERE REMOFVED FROM THE JOINT AND FLUID SUCTIONED FROM THE SUBACROMIAL SPACE.  A 2 cm INCISION WAS MADE AT THE INFERIOR BORDER OF THE PECTORALIS MAJOR TENDON.  BLUNT SCISSOR DISSECTION WAS USED TO CARRY THE INCISION DOWN UNDERNEATH THE PECTORALIS MAJOR, AND SHORT HEAD OF THE BICEPS WAS IDENTIFIED.  BLUNT RETRACTORS WERE PLACED TO RETRACT THESE MUSCLES AND TO EXPOSE THE ANTERIOR HUMERUS.  THE LONG HEAD OF THE BICEPS WAS EASILY IDENTIFIED AND DELIVERED INTO THE WOUND WITH A RIGHT ANGLE CLAMP.  A 1.5 X 1 cm AREA FOR BICEPS TENODESIS WAS PREPARED AT THE TERMINAL ASPECCT OF THE BICIPITAL GROOVE, JUST BELOW THE PECTORALIS MAJOR TENDON, USING A CURRETTE TO ROUGHEN THE BONE.  A 2.9 MM ANCHOR WAS PLACED IN THE CENTER OF THE REPAIR SITE AND HAD EXCELLENT PURCHASE IN THE BONE.  THE SUTURE LIMBS WERE PASSED THROUGH THE TENDON WITH A COMBINATION OF CURVED MAYO NEEDLE AND ARTHROSCOPIC PENETRATOR.  THE LATERAL SUTURES WERE PASSED IN A LOCKING LASSO-LOOP CONFIGURATION WITH THE PENETRATOR.  THE MEDIAL SUTURES WERE PASSED WITH THE MAYO NEEDLE USING A RUNNING, LOCKING KRACKOW CONFIGURATION AT THE MUSCULOTENDINOUS JUNCTION.  THE EXCESS TENDON WAS RESECTED WITH A SCALPEL.  THE SUTURES WERE TIED AND CUT, REDUCING THE TENDON TIGHTLY DOWN TO THE BONE. THE WOUND WAS THOROUGHLY IRRIGATED WITH NORMAL SALINE. (THEN THE SUBCUTANEOUS TISSUE, SKIN AND PORTALS WERE STITCHED CLOSED.

THANKS AGAIN!!


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## Deb Jones - CPC (Sep 17, 2012)

No takers?
How about - what code would you use for paralabral cyst removal (open or arthroscopic)?

Thanks for any input!
Deb


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