# Reverse shoulder arthroscopy and bundling



## esimonsen (Mar 22, 2017)

Help please please please!  Our coding service said one of our docs is reporting a bunch of coding for a reverse shoulder arthroscopy that they say are bundled.  I am not finding any NCCI edits, and I don't know if that means that it is such a "duh" bundle that they don't have an edit for it, or if I am just not well versed enough in shoulder and so don't get it.  Is he just saying the same thing twice by reporting all these codes plus the reverse shoulder?

the feedback we received was "The provider is indicating to code the following CPT codes 24400 (lesser tuberosity osteotomy), 23630 (open reduction internal fixation of tuberosity osteotomy) and 23020 (capsular contracture release of entire subscap off anterior scapula) as well as 23430 (tenodesis of the long head of biceps,)  in addition to 23472 (total shoulder).  Based upon the coding review of the documentation only the total shoulder CPT 23472 would be appropriate to code.    I wanted to bring this to your attention to see if the provider feels there is something different with these cases where the coding should be unbundled?"


POSTOPERATIVE DIAGNOSES:

1.  M19.012:  Left shoulder osteoarthritis. 

2.  S43.022S:  B2 Walch posteriorly subluxed humeral head on the glenoid.


OPERATION:

1.  23472:  Total shoulder arthroplasty with Simplicity humeral component and

shoulder Innovations inset glenoid component, 8 mm depth.

2.  24400:  Lesser tuberosity osteotomy.

3.  23630:  Open reduction internal fixation of tuberosity osteotomy.

4.  23020:  Capsular contracture release of entire subscapularis off anterior scapula.

5.  23430:  Tenodesis of the long head of biceps.

PATHOLOGY:  This patient had osteoarthritis with a fixed posterior subluxation

of the humeral head with a B2 posteriorly eroded glenoid.  The rotator cuff

was intact.

DESCRIPTION OF PROCEDURE:  The patient was placed on the operative table. 

After the timeout ritual, a left deltopectoral incision was carried through

the skin, subcutaneous tissue and deltopectoral interval while preserving the

cephalic vein with the deltoid.  The subacromial, subdeltoid and subcoracoid

spaces were freed.  The long head of the biceps was tenodesed to the upper

pectoralis and then resected proximal to that.  The lesser tuberosity was

osteotomized and retracted as the inferior capsule was released.  The rotator

interval was opened.  The head was delivered to the deltopectoral interval. 

Marginal osteophytes were removed and with the ring cutting guide.  The head

was osteotomized at the anatomic neck with the #2 nucleus and trialing the 46

mm humeral head fit best.  The triflange nucleus was impacted in place.  A cut

protector was put on this.  The head was retracted posteriorly.  The glenoid

was exposed.  The coracohumeral ligaments and the entire anterior capsule were

excised, as the subscapularis was elevated off of the anterior scapula. 

Aiming for Matsen's center point along Friedman's line, the version was

corrected using a Steinmann pin and a reamer with the next largest size of the

reamer.  It was reamed so that eversion would be restored closer to neutral. 

It was inset deeper into the anterior glenoid than the posterior glenoid.  The

3 drill holes were created for the inline pegs to be cemented.



After the cement dried, 3 holes were made in the biceps groove.  Nice loop

sutures were passed through the drill holes.  The prosthesis was impacted into

place.  The shoulder was reduced.  The lesser tuberosity was repaired by

passing these sutures medial to the lesser tuberosity osteotomy, and then

racking hitch sutures were used to secure the tuberosity securely back to the

humerus.  The rotator interval was partially closed.

The deep and superficial tissues were closed over vancomycin powder. 

Steri-Strips were used for the skin.  The patient was transferred to Recovery

Room in good condition.[/SIZE]


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## AlanPechacek (Mar 28, 2017)

After reviewing the Operative Report (more than once) it appears that your surgeon is a "Master of Unbundling."  The first thing that "pops up" is the diagnosis "B2 Walch posteriorly subluxed humeral head on the glenoid."  In Osteoarthritis of the Glenohumeral Joint, it is not uncommon for there to be "erosion" of the posterior glenoid by the degenerative processes, such that there can be some posterior subluxation of the humeral head.  This is not a Traumatic condition (S Code) unless there is a clear past history of glenoid fracture that could result in this phenomenon, and/or a clear history of recurrent posterior dislocations of the shoulder that could result in the posterior glenoid erosion or defect.  Including this diagnosis in the Postoperative Diagnosis list does indicate that the procedure was somewhat more difficult than usual, and had to be "corrected" or accounted for in the procedure in the form of additional work (Modifier 22: Increased Procedural Service).  About the only ICD-10 code I could find that might apply to the "posterior subluxation" of the humeral head is M99.17: Complex "Subluxation" of the upper extremity.  This Code Set is very confusing because it seems to focus on or apply mainly to spinal/vertebral subluxation, but then it includes the 5th character 7 for the upper extremity, which would include the shoulder, but certainly is not spinal/vertebral.  Unless there is a history of recurrent dislocation or subluxation, neither M24.31 _: Pathologic "dislocation" of the shoulder would not apply, since it seems to be pretty specific and does not include "subluxation," nor would M24.41 _:  Recurrent Dislocation or Subluxation of the Shoulder since there is no history of such, at least not in the Op Report.

As for the procedure itself, it appears that he did a conventional Shoulder Arthroplasty, not a Reverse Arthroplasty.  Most everything he does in the procedure would be an integral part of it, except the Biceps Tenodesis.  In opening the shoulder joint from anterior, the Subscapularis muscle and tendon and anterior capsule have to be "opened" in order to enter/expose the joint for the preparation and placement of the prosthetic components.  Some surgeons remove them by dissecting them off of the Lesser Tuberosity, and others may osteotomize the Lesser Tuberosity to accomplish the same thing.  Either way, the bone fragment or the muscle/tendon have to be repaired back during the closure part of the procedure.  The debridement or dissection of the anterior capsule is also an integral part of the procedure in order to access the joint and remove scarred or contracted tissue, similar to removing any osteophytes around the humeral neck or elsewhere.  So, the Lesser Tuberosity Osteotomy, the Open Reduction and Internal Fixation of the Lesser Tuberosity Osteotomy, and the Anterior Capsular Contracture Release of the entire Subscapularis off of the Anterior Scapula (Glenoid ) would all be "integral" parts of the procedure, not separate.

As for the Biceps Tenodesis, he provides no indications or rational for doing this.  It is not always necessary, nor a part of doing a "conventional" shoulder arthroplasty, unless there is tendon pathology that would indicate that it would be the proper thing to do.  If this is something he "always" does in this procedure, then I would consider it to be an integral part of the procedure.  If it is not his "normal" procedure to do the Tenodesis, then he would have to document the pathology and rational for doing so.  With that, it could probably be coded with a Modifier (probably 51) as well.  

Although I do not have a current copy and can not quote from it, the AAOS has a publication: Complete Global Service Data for Orthopedic Surgery, 2017.  As usual, it is pretty expensive to buy, but it delineates and defines what is "included" as the "integral parts" of surgical procedures.  I believe it would support my opinion as it regards the surgical procedure as described. 

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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## daedolos (Feb 23, 2018)

Thanks for that detailed analysis, Doctor Pechacek.  I've been coding a lot of total shoulder arthroplasties lately and your description of the reasoning behind procedures has helped me a lot.

Peace
@_^


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