# Arthroscopic plus open shoulder surgery



## Desperate Denise (Jun 6, 2010)

Hey guys - another quick question.

I am constantly in discussions (lets call it that) with the physicians about arthroscopic subacromial decompression and labral debridements performed with mini-open rotator cuff tears.

I have taught that with open rotator cuff repairs (23412) the 29826 would be included in the open procedure.  The 29822 in this scenario appears to be bundled with 29826.

If you could please comment on this opnote and assist me with obtaining any literature to present to the physicians at my next meeting it would be so overwhelmingly appreciated.


 POSTOPERATIVE  DIAGNOSIS:   Left  shoulder  massive  rotator  cuff   tear,
 impingement syndrome, labral tear.

 OPERATION PERFORMED:  Left shoulder arthroscopy.
 Arthroscopic labral debridement of type 1 tear.
 Arthroscopic subacromial decompression.
 Mini open repair of massive rotator cuff tear.

 and placed supine on the operating room table.  After induction of general
 anesthetic,  she  was  placed  in  a  beach  chair  position.   All   bony
 prominences were padded.  A posterior portal was created.  Examination  of
 the  shoulder  showed normal glenohumeral articular surfaces.   There  was
 fraying  of  the superior aspect of the subscapularis tendon.  The  biceps
 tendon  was absent intraarticularly.  There was a tear extending from  the
 top  of  the  subscapularis down to the infraspinatus.   The  tear  was  a
 crescent-shaped tear and had delamination component to it.  The labrum had
 a type 1 tear right at the biceps attachment which was debrided with a 4.5
 mm  full-radius  shaver.  Attention was directed to the subacromial  space
 where a type 3 acromion was visualized and acromioplasty was performed.  A
 mini  open rotator cuff tear was carried out with dissection down  through
 skin  and  deltoid fascia.  The superior leaf was debrided.   The  greater
 tuberosity was debrided with a 5.0 bur.  There was blood coming  from  the
 greater tuberosity.  The tendon edges were debrided and a traction  suture
 was  placed.  The traction suture showed there was a crescent-shaped tear.
 No  need  for  convergence  sutures.   The  5.5  PEEK  anchor  was  placed
 posteriorly.   An  attempt at a 5.5 PEEK anchor  was  placed  in  the  mid
 tuberosity and it pulled out.  A 6.5 anchor also pulled out.  A 5.5 anchor
 PEEK  anchor was then placed anterior to the weak tuberosity bone.  The  4
 sutures  were  placed in a horizontal mattress fashion.  These  were  then
 tied  down, and two 4.5 suture lock anchors were placed laterally inferior
 to  the greater tuberosity.  The tendon edges were brought down nicely and
 covering the footprint of the greater tuberosity.  There was no tension on
 the  repair.   The  arm  could  be placed at the  side  comfortably.   The
 shoulder  was  irrigated.  The deltoid fascia was  closed  with  0  Vicryl
 suture, 2-0 Vicryl in the subcutaneous tissue,  4-0 Monocryl in the skin.  Steri-Strips and dry sterile  dressing...


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## DOVERRED (Jun 6, 2010)

only a diagnosic athroscopy is included  in the open procedure


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## coderguy1939 (Jun 7, 2010)

You didn't include carrier information which may impact what is allowed, but take a look at this information on the subject at the AAOS website.

http://www.aaos.org/news/aaosnow/mar09/managing3.asp

It's the second or third question and seems to be pretty much the same scenario you've described.


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## Bella Cullen (Jun 9, 2010)

I would bill this as 23412, 29826, 29822, and check CCI edits because I think one or two codes requires a 59 modifier.


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## delphinus777 (Jun 9, 2010)

Becasue the surgeon went from arthroscopic to an open technique to complete different procedures, you can code for both. Had he started the RTC repair arthroscopically and then went to an open you could only code the open.  In the orhtopedic coding alert [2010, Vol. 13 no. 4] it states just that.  The arthroscopic procedures get the 59 modifier.


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## Desperate Denise (Jun 9, 2010)

*Shoulder surgery*

Thank you Delphinus777, Bella Cullen, Coderguy and Doverred - I really appreciate your clarification.


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