# Type II Slap Repair



## dyoungberg (Aug 10, 2012)

I would like to have a second opinion on my ASC coding of this procedure:

*PREOP DIAGNOSIS:  	LEFT SHOULDER SLAP TEAR 

POSTOP DIAGNOSIS: 	LEFT SHOULDER SLAP TEAR AND GLENOHUMERAL JOINT CHONDROSIS 

PROCEDURE: 
1. LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY 
2. LEFT SHOULDER ARTHROSCOPIC SLAP REPAIR 
3. LEFT SHOULDER ARTHROSCOPIC CHONDROPLASTY AND SYNOVECTOMY 

ANESTHESIA:       GENERAL 

SPECIMEN: 	   NONE

DRAINS: 	   NONE 

COMPLICATIONS:  NONE 

EBL: 		    MINIMAL

IMPLANT:              MITEK GRYPHON BR SUTURE ANCHORS X TWO 

CONDITION:   	    PATIENT EXTUBATED AND TAKEN TO THE RECOVERY ROOM IN GOOD CONDITION 

INTRAOPERATIVE FINDINGS:  
1.  Type II SLAP tear. 
2.  Fraying without detachment of the anterior, inferior and posterior labrums. 
3.  Diffuse grade III-IV chondral wear of the humeral head and glenoid without bone loss. 
4.  No evidence of posterior, mid or anterior rotator cuff tear. 
5.  Minimal biceps tendinopathy and no tearing. 
6.  Subscapularis intact. 

INDICATIONS FOR PROCEDURE: Patient is a 45 year old male with a long history of left shoulder pain dating back to an injury sustained while on active duty. The patient had failed maximum nonoperative treatment and sought surgical consult. The risks and benefits of surgery were discussed with the patient and he was given the opportunity to ask questions regarding his treatment plan. When his questions were answered to his satisfaction, he elected to proceed with surgery and signed informed consent. 

PROCEDURE IN DETAIL:   The patient was greeted in the preoperative holding area where the left shoulder was correctly identified and initialed as the surgical site. He was then administered an interscalene block by anesthesia for postoperative pain management. Next, he was brought back to the operating room for his procedure where he was placed supine on the OR table and appropriate cardiopulmonary monitoring devices were connected. 1 gram Ancef was given intravenously and bony prominences were well padded.  SCD's were placed on both lower extremities. He was then administered general anesthesia and intubated. The left shoulder was examined under anesthesia and found to have a ROM of 180 degrees of forward flexion and abduction, 90 degrees external rotation with the arm at the side and when abducted, and 90 degrees internal rotation with the arm abducted. These findings were all symmetric to the unaffected side and no evidence of anterior, posterior or inferior instability was noted. He was then placed in a beach chair position with his head held in a well-padded neutral fashion and the LUE was prepped and draped in a standard surgical fashion. An appropriate surgical timeout was performed to confirm the patient as Joseph May and the surgical site as the left shoulder. Then bony landmarks and incisions were drawn on the skin and the subcutaneous tissue was infiltrated with approximately 7 cc 0.25% Marcaine w/epinephrine.  

A posterior portal was used to gain access into the joint and diagnostic arthroscopy began with evaluation of the 
rotator interval which had synovitis but no evidence of instability. An anterior portal was established under direct visualization and an arthroscopic probe was placed into the shoulder joint to evaluate fraying without attachment of the anterior and inferior labrum. The posterior labrum also had fraying and the superior labrum had a fair amount of synovitic fraying with instability of the biceps anchor consistent with a type II SLAP tear. The extra articular portion of the biceps tendon was brought into the shoulder joint and minimal tendinopathy was noted in its course and no evidence of intratendinous tearing was noted. The subscapularis tendon was evaluated in internal and external rotation and noted to be well attached to the lesser tuberosity. Fairly diffuse grade III-IV changes were noted throughout the humeral head and the glenoid without any significant bone loss but with loose chondral flaps. The axillary recess was free and clear of any loose bodies and the posterior, mid and anterior rotator cuff were intact without any evidence of tearing. 

At this point and time the decision was made to proceed with a SLAP repair and an anterior superolateral portal was established under direct visualization and the superior glenoid was prepared back to a bleeding bone bed after first debriding the synovitis and labral fraying from the edges of the anterior and superior labrums. The scope was switched to the anterior cannula and we once again evaluated the posterior labrum which had fraying without detachment and the frayed labrum was debrided. Any loose fragments of cartilage were removed with a basket forceps and debrided back to a stable rim with an arthroscopic shaver and then we moved the camera back to the posterior portal and placed a double loaded Mitek gryphon suture anchor at the anchoring point of the biceps tendon. We used our suture passing devices to pass our sutures around the biceps tendon to stabilize it and securing it with a sliding knot and three alternating half-hitches. We placed a second single loaded anchor at the posterior superior aspect of the glenoid and once again passed the suture around the labrum and secured it with a sliding knot and three alternating half-hitches. We then tested our repair for stability nothing reestablishment of the biceps anchor to its normal anatomic position and eliminating the instability at the superior labrum. Once this was completed we removed our instruments from the joint and injected an additional 10 cc 0.25% Marcaine with epinephrine. 

We closed all incisions with 4-0 Monocryl suture in the subcuticular layer and used Dermabond to approximate the skin.  A sterile dressing was then placed before the drapes were removed and then the arm was placed in an abduction sling before the patient was laid back in the supine position. 

Next, he was awakened, extubated, and taken to the recovery room in good condition. 

Sponge and instrument counts were correct x two at the end of case.  There were no known orthopedic complications for this case. 

POSTOPERATIVE PLAN:     The patient will be discharged home pending passing postanesthesia criteria.  Follow up in two weeks for a wound check.  He will begin physical therapy per postoperative protocol including six weeks in a sling with passive ROM only. *

I coded this as 29807 & 29822 and Tricare has denied payment of 29822 stating it's inclusive in 29807.  Any ideas as to why they would deny and should I have coded this differently?

Thanks very much!

Debbie Youngberg
CPC-A
NW FL Surgery Center


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## nyyankees (Aug 13, 2012)

dyoungberg said:


> I would like to have a second opinion on my ASC coding of this procedure:
> 
> *PREOP DIAGNOSIS:  	LEFT SHOULDER SLAP TEAR
> 
> ...



looks like 29822 will be part of 29807 - fraying and synovitis is on labrum...


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