# Shoulder Sx Clarification Please



## aprilroc (Aug 13, 2009)

The OP note reads:

The anterosuperior glenoid labrum just underneath and anterior to the biceps anchor was debrided with a 4/0 round bur and a 4/5 motorized shaver to get to nice bleeding bone. We placed 1 glenoid anchor here, passed the suture in vertical mattress fashion using a BirdBeak suture passer. We then flipped our viewing portal anteriorly and examined the posterior labrum, We elected to do simply a posterior repair with suture only and capsulorraphy due to the fact that the labral tear was about 1 cm off the glenoid rim and did not feel that anchor placement here would add any advantage. We, therfore made an accessory posteroinferior portal under needle localization and passed sutures x 2 through the outer capsule/labral junction into the glenolabral junction and then tied these sequentially. This affected a nice repair of the posterior labral tear and gave some tightening of the capsule posteriorly, as well. 

I am confused as to which code to use. Any help would be appreciated. 

Thanks,


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## mbort (Aug 13, 2009)

look at 29806


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## aprilroc (Aug 13, 2009)

Thanks Mary

That was exactly what I thought, but the Dr coded it differently. When I have to go against them I always want a second opinion.


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## aprilroc (Aug 17, 2009)

Ok, After talking to my Dr. He said that the labrum is 3 parts superior (which is the SLAP repair), the posterior and anterior. When the patient has a tear in another part of the labrum other than the SLAP then it warrants reporting a 29806 in addition. In the above OP note he says that he did a repair of the SLAP the first part and where it begins we elected to simply do a posterior he says this is the capsuloraphhy in the posterior part of the labrum. 

Does anybody agree with this?


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## mbort (Aug 17, 2009)

from AAOS:

"CPT code 29806 - Arthroscopy, shoulder, surgical; capsulorrhaphy. When this code was added, it became the parent code in the shoulder scope section per CPT guidelines–regarding intended procedures. Thus, the notes under code 29806 can technically pertain to any of the codes in the indented series with the notes indicating for "open procedures, see 23450-23466." With this note appearing directly under CPT code 29806, many thought that this represented an arthroscopic bankart procedure. CPT code 29807 - Arthroscopy, surgical; repair of a superior labrum anterior/posterior (SLAP) lesion. The American Medical Association (AMA) publication, CPT Changes 2003, An Insider's View, references the following: "Code 29807 is another new arthroscopic shoulder procedure code intended to be reported when arthroscopic shoulder stabilization and repair of SLAP lesions are performed." Keep in mind the word "stabilization" can mean many things. However, when it comes to a SLAP lesion repair–even though you may need to go through the capsule to tack the suture/staple–this would normally not be considered a separately reportable procedure. Since there has been no direct linkage under this code to an open counterpart, more confusion arose. However, under CPT code 23455, it states, "to use 29807 for arthroscopic procedure." 
This provides a direct link from open bankart to scope bankart. AAOS Global Service Data book In the book, AAOS Complete Global Service Data for Orthopaedic Surgery, there is further reference to when coders/physicians can report 29806 and 29807 together during the same operative session. Be clear in operative reports Surgeons need to be clear in their operative reports of the type of SLAP lesion being repaired. They also need to be clear that two separate lesions are being operated on: SLAP lesions and a capsular defect. Medicare's National Correct Coding Initiative (NCCI) The NCCI edits state that 29806 and 29807 are bundled with a status indicator of "1," meaning if an appropriate modifier is used, billing may take place. For an appropriate modifier to be appended, there must be indication of separate site, separate lesion and/or separate session. Examples: A surgeon performs an arthroscopic anterior and posterior capsulorrhaphy. How would this be coded? CPT code 29806 would be reported only once. It would be inappropriate to report this code twice because just one capsule is being repaired. Patient presents with an anterior-inferior capsular defect resulting in instability. Surgeon performs a capsulorrhaphy during which a SLAP 2 lesion is encountered. How would this be coded? Codes 29806 and 29807-59 would be reported. Since two separate lesions were identified, this supports the reporting of the two codes. Patient presents with a SLAP lesion and surgeon performs arthroscopic SLAP lesion repair. There is reference in the operative report of suture brought up through the capsule. How would this be coded? CPT Code 29807 would be the appropriate code to represent this surgical technique. Since the lesion identified is that of a SLAP, the repair–which includes going through the capsule for stabilization–would not meet the guidelines of a "true" capsulorrhaphy. When doing a SLAP lesion repair, the lesion is caused by the tendon actually pulling the labrum loose from the capsule. These types of SLAP lesions require repair and this is normally done by placing some sort of suture/anchor/staple through the labrum and into the bone. To do this, the staple has to go through the capsule to get to the bone, but this does not mean that a capsulorrhaphy was done. " http://www2.aaos.org/aaos/archives/bulletin/apr04/code.htm "Procedures to correct instability Instability is usually caused by either a defect at the insertion of the capsule into the rim of the glenoid (Bankhart lesion) or a generally loose capsule. The procedure to correct the instability depends on the cause. In addition, occasionally both a Bankhart lesion and a redundant capsule are seen in the same shoulder. The Bankhart lesion can be posterior or inferior but is usually in the anterior/inferior position of the glenoid. There are a number of ways to address instability. The most common way to address the Bankhart lesion is to repair the capsule to the glenoid by using either sutures or staples. If the capsule is loose, adjunctive thermal capsulorrhaphy or another form of capsular reefing is done. Closure of the rotator INTERVAL is one form of capsular reefing. Other procedures, such as the Putti-Platt or other muscular or capsular transfers that are designed to limit external rotation, are done less commonly now that surgeons have a better understanding of shoulder mechanics. For recalcitrant problems, some form of bone block procedure such as the Bristow can be done, either anteriorly or posteriorly. If a capsular-tightening procedure is required, capsular shifts, sometimes supplemented with thermal capsulorrhaphy, are done. Specific codes are used with both the Putti-Platt or Magnuson (23450, “Capsulorrhaphy, anterior, Putti-Plat procedure of Magnuson type operation”) and the Bankhart repair with labral repair (23455, “Bankhart procedure or other similar repair of the capsule directly to the glenoid rim”). Similarly, there are specific codes for an anterior bone block (23460), for posterior bone block (23465) and for coracoid process transfer (23642). Any of the capsular shift procedures and capsulorrhaphy procedures for multidirectional instability is coded 23466. If thermal capsulorrhaphy is used for augmentation, 29999-51 should be coded. Coding for thermal capsulorrhaphy can sometimes be confusing. There is no code for thermal capsulorrhaphy. If it is the only procedure performed, use code 29999 (Unlisted procedure, arthroscopy). This procedure is performed for instability and if it is used as an adjunct to other capsular procedures, coding 29999-51 is appropriate. Sometimes the rotator INTERVAL is closed to address instability. If this is the only procedure done, use code 29806 (Arthroscopy, shoulder, surgical, capsulorrhaphy). If other capsulorrhaphy procedures are performed to address the instability, the ROTATOR CUFF INTERVAL closure is included in the capsulorrhaphy and should not be coded separately. It is inappropriate to report a rotator INTERVAL closure with a ROTATOR CUFF repair. SLAP Lesions There are several ways to code repairs of SLAP lesions. Which code to use depends on the type of SLAP lesion and what was done. Repair (debridement) of a type I SLAP lesion is always coded as 29822 (Arthroscopic debridement, limited). Repairs of types II and IV SLAP lesions are coded 29807 (Repair SLAP lesion) because an actual repair is performed. Type III SLAP lesions are bucket-handle tears and can be either debrided or repaired; use 29822 or 29807, whichever is appropriate. Adding code 29806 (Arthroscopy, shoulder, surgical, capsulorrhaphy) for repair of a SLAP lesion is never appropriate unless there is a capsular defect in an area different than the SLAP. This is one of the most common coding errors. Even if a staple or other device goes through the capsule to repair the SLAP, capsulorrhaphy should not be coded separately."


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## aprilroc (Aug 17, 2009)

I have reviewed all that information and am still confused. Do you agree that if a tear in another part of the labrum seperate from the SLAP is repaired with suture it could warrant reporting 29806 in addition to 29807 if they both were repaired? I don't know why this is so confusing to me.


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## mbort (Aug 17, 2009)

no I do not personally think his note supports the use of both codes.  I would show him what I posted.  His note needs to be MUCH more detailed if he wants to capture both codes.  He only calls this a labrum tear in his note, he never mentions that it is a SLAP nor whether is a type I,II,III or IV.


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