# Another Shoulder Surgery



## dyoungberg (Dec 19, 2012)

I've got another Arthroscopic Shoulder Surgery that's got me baffled.  I've been told if the same procedure is done is different compartments of the shoulder, we can bill additionally for this.  Can anyone tell me if this is correct?

I've chosen theses codes for the following surgery:  29827,29827-59,29826,29824,29823-59, & 29820.  Am I at least the right ball park?

PROCEDURE:	
1.	LEFT SHOULDER MANIPULATION UNDER ANESTHESIA
2. 	LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY 
3. 	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH DEBRIDEMENT OF ROTATOR CUFF TENDON AND LABRAL TEARS
4.	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH GLENOHUMERAL SYNOVECTOMY
5.	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH BICEPS TENOTOMY
PROCEDURE: (continued) 
6.	LEFT SHOULDER ALL ARTHROSCOPIC REPAIR WITH ALL INSIDE TECHNIQUE OF SUBSCAPULARIS TENDON TEAR
7.	LEFT SHOULDER DIAGNOSTIC BURSOSCOPY
8.	LEFT SHOULDER OPERATIVE BURSOSCOPY WITH:
A.  	DEBRIDEMENT BURSAL SIDE TEAR ROTATOR CUFF TENDON 
B.	SUBACROMIAL DECOMPRESSION (SUBTOTAL BURSECTOMY, AND ACROMIOPLASTY WITHOUT CORACOACROMIAL LIGAMENT RESECTION)
C.	MUMFORD PROCEDURE (EXCISION OF DISTAL THIRD OF CLAVICLE)
9.	LEFT SHOULDER ARTHROSCOPIC REPAIR, ROTATOR CUFF TENDON, SUPRASPINATUS AND INFRASPINATUS PORTIONS  
10.	LEFT SHOULDER APPLICATION MICROFRACTURE TECHNIQUE TO CREATE MARROW VENTS TO THE GREATER TUBEROSITY AND TO STIMULATE BONE-TENDON HEALING RESPONSE KNOWN AS CRIMSON DUVET

ANESTHESIA:	GENERAL


IMPLANT: 		ARTHREX 5.5 MM FULL THREADED CORKSCREW TRIPLEPLAY SUTURE ANCHORS x 2 WITH ATTACHED #2 FIBERWIRE x 3 PER ANCHOR FOR A TOTAL OF 6 SUTURES ATTACHED TO AN ANCHOR AND AN ADDITIONAL 2 SUTURES UTILIZED IN A SIDE TO SIDE MANNER, ALSO #2 FIBERWIRE 

COMPLICATIONS:  	NONE NOTED

EBL: 			MINIMAL 

FINDINGS: 
With the patient asleep, he was found to have very limited passive range of motion of the shoulder to just 95 degrees of flexion and 105 abduction.  A gentle manipulation was done, initially in flexion, and I was able to improve that motion to 135 degrees without suggestion of iatrogenic fracture, followed by putting the arm back to the side and then into an abducted manner with manipulating him up to about 135 degrees without any concern for iatrogenic fracture.  No attempt was made to improve external rotation for fear of iatrogenic fracture.  

Upon entering the joint, there was a mild hemarthrosis present consistent with manipulation.  There was abundant soft tissue tearing present that really made it quite difficult to even evaluate the shoulder in terms of anatomy, due to the extensive tearing seen.  Biceps tendon had at least 90-95% of a tear with just a few fibers remaining of same and that was treated by arthroscopic biceps tenotomy.  There was extensive tearing of the rotator cuff as had been suggested on preop evaluation and this included 75% partial tear of subscapularis and complete tears of the entire supraspinatus/infraspinatus tendons with retraction medial to the level of the glenoid labrum.  Extensive synovitis was seen and this was treated by synovectomy to remove hypertrophic synovium and to do a release anteriorly to try to improve his range of motion postoperatively.  I released the superior glenohumeral ligament, the middle glenohumeral ligament and a portion of the anterior inferior glenohumeral ligament in the course of the synovectomy anteriorly.  Subscapularis tendon was then repaired anatomically as described below.  This repair was separate than the repair to the supraspinatus and infraspinatus done through separate portal, separate compartment using separate implants and instrumentation.  Anatomic repair of the subscapularis tendon was achieved.  Intraarticular release of the retracted supraspinatus/infraspinatus was done using Liberator elevator to release the capsule articular side through the lateral portal.  There was very poor mobilization of the tissue, even despite the releases however.  Superior one-third of the labrum was torn and treated by debridement using full radius resector and cautery device.  Articular surfaces looked fairly good.  


In the bursa there was noted to be significant bursal hypertrophy present.  This required a significant amount of time to accomplish subtotal bursectomy using combination of a full radius resector and an electrocautery device.  Severely retracted rotator cuff was noted, consistent with a “bald eagle” appearance.  There was evidence of articulation of the humeral head on the undersurface of the acromion and, for this reason, the CA ligament was maintained and a small amount of subacromial bone was removed while maintaining that CA ligament intact using the bur in a reverse manner and on the reverse setting.  This was done uneventfully and that ligament was preserved.  Prominent AC joint was seen to be impinging upon the area of the rotator cuff, treated by distal clavicular resection.  Approximately 6 mm of subacromial bone was removed in the course of the acromioplasty.  

A repair of the rotator cuff supraspinatus and infraspinatus was done by initially removing soft tissue off the humerus and then preparing the humerus for tendon healing purposes by lightly abrading the cartilage using the bur on the reverse setting to expose subchondral bone without creating a trough.  Additional mobilization of the rotator cuff was required and I incised the connection between the anterior supraspinatus and the subscapularis. 

This helped mobilize the anterior supraspinatus somewhat.  With care I was able to further mobilize the articular and bursal sides of that tear involving the supraspinatus and infraspinatus and this tear seemed to be most amenable to a margin convergence technique.  Two #2 FiberWires were utilized to create a margin convergence of this tear and it nicely closed the 5 cm tear down to about 2.5 to 3 cm.  I then utilized two Arthrex 5.5 mm TriplePlay suture anchor screws, separated by about a cm or so, placed through an accessory lateral “anchor” portal that was developed using needle localization technique, to place both anchors on the articular margin.  These anchors were inserted individually, beginning anteriorly and progressing posteriorly once all sutures had been passed.  Sutures were passed beginning anteriorly and progressing posteriorly using the appropriate suturing device and allowing simple suture repair for a single row technique.  Each suture was passed and tied using six alternating half hitches, switching posts between the third and fourth half hitch. I was able to get a tension free repair with a watertight repair by somewhat medializing the rotator cuff.  In the course of the repair, multiple marrow vents were placed, both medially and laterally, to the repair with care to avoid compromising suture anchor screws.  Marrow vent technique is described below. 

DESCRIPTION OF PROCEDURE:

LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY:  
Following proper identification of the patient on the operating room table, a “timeout” was done to insure correct patient, body part, operative procedure, and to identify any known allergies.  It was also confirmed that the patient was administered preoperative antibiotics with the operating team's goal of having incision time within one hour of said administration (unless vancomycin or fluoroquinolones are used because of the longer infusion time of these drugs).  General endotracheal anesthesia was administered without difficulty.  The patient was placed in the lateral decubitus position on a bean bag with the affected shoulder up. The arm was prepped and draped in the usual sterile fashion after manipulation of the shoulder under anesthesia with findings as noted above.  The patient's arm was then placed in the Arthrex shoulder holder using the arm suspension device with 10 pounds of weight.  Anatomical landmarks were outlined with a marking pencil.  The joint was entered with 18G spinal needle and distended with 10 cc 0.5% plain Ropivacaine mixed with 20 cc normal saline.  A small stab wound was made and the scope sheath inserted with a blunt tipped obturator, followed by the arthroscope.  After joint distension, a second portal was created just below the biceps tendon with an inside-out technique using a transarticular rod for guidance.  With through-and-through irrigation established, the anatomy was carefully viewed from both anterior and posterior portals.  


LEFT SHOULDER OPERATIVE ARTHROSCOPY:  
Once through-and-through irrigation was established, the anatomy was carefully viewed from both anterior and posterior portals with anatomic and pathologic findings as noted above under “Findings.”  Intraarticular pathology was addressed as indicated.  Debridement was performed, as indicated above, using combination of full radius resector and electrocautery device.

Details of the biceps tenotomy are also described above.  

LEFT SHOULDER ALL ARTHROSCOPIC REPAIR WITH ALL INSIDE TECHNIQUE OF SUBSCAPULARIS TENDON TEAR:
Subscapularis was torn and retracted from the lesser tuberosity with small remnant of intact subscapularis tendon seen to be attached which allowed grasping of the tendon medially and retracting for repair which was accomplished using all arthroscopic technique.  This was a separate repair from the repair of the rotator cuff supraspinatus and infraspinatus portions that was accomplished within the bursal space.  The repair of the subscapularis tendon was all done within the joint and required special portals and instrumentation to accomplish this.  A portal was developed that allowed passage of the Spectrum suture device and placement of an anchor to secure sutures into the lesser tuberosity.  Once the portal was developed, the area of the lesser tuberosity was abraded of soft tissue and lightly decorticated using a bur to get bleeding surface for healing of soft tissue through a healing response.  The subscapularis tendon was then sutured by passage of #1 PDS ligature through the tendon as it was retracted, and the suture was then retrieved through the lateral portal.  The suture was utilized as a shuttle type suture to allow passage of #2 FiberWire.  The first suture then served as a traction stitch and allowed passage of another suture more medial to that one.  Gentle retraction was done and appeared to allow for excellent anatomic repair of the tendon, and this was then secured by placing a single Arthrex 4.5 mm PushLock suture anchor through a punch hole.  Sutures were placed in the anchor and driven into the prepunched hole with excellent fixation of the tendon back to the bone achieved.  

Note that this repair was completely separate from the repair done through the bursa through separate portals required to repair the supraspinatus rotator cuff tendon tear.  This repair of the subscapularis tendon required separate portals and instrumentation in order to repair this tendon tear through the glenohumeral joint and was able to be done in avoidance of an additional open procedure to this patient's shoulder. 

At the conclusion of the arthroscopic portion of the procedure, all instruments were removed in order to proceed to bursoscopy.

LEFT SHOULDER DIAGNOSTIC BURSOSCOPY: 
The arm was then changed to the bursoscopy position, and 15 pounds of weight was used for suspension of the extremity.  The arthroscope which had been removed from the shoulder joint at the conclusion of the operative arthroscopy portion of the procedure was then carefully inserted into the subacromial space using the posterior-inferior border of the acromion as a guide to it.  A blunt tipped trocar was used with the cannula, and once properly placed in the bursa, a transbursal guide rod was used in order to place an anterior cannula.  Once free flow of fluid was established both anteriorly and posteriorly, the bursal anatomy was viewed carefully from both portals with anatomic and pathologic findings as noted above under “Findings.”

LEFT SHOULDER OPERATIVE BURSOSCOPY:  
Once a complete inspection of the bursa was completed, pathology was addressed as noted above under “Findings.”

Subtotal bursectomy was accomplished using a combination of full radius resector and electrocautery device.  It did require a significant amount of time to perform this portion of the procedure secondary to abundant bursitis.  The rotator cuff pathology, as described above under “Findings”, was treated with similar instrumentation.  

LEFT SHOULDER SUBACROMIAL DECOMPRESSION:  
A third portal was made in the mid lateral subacromial area using a blunt-tipped plastic obturator and an operating cannula using a needle localization technique and was located approximately 2.5 cm lateral to lateral edge of acromion.  The shaver was inserted through the plastic cannula, and the bursal tissues adherent to the cuff were debrided once again.  An electrical surgical tool was inserted and used to transect and morselize soft tissues beneath the undersurface of the acromion.  The coracoacromial ligament was carefully maintained in the course of the procedure.  The shaver was used to remove debris.  A high speed bur was used for the acromioplasty to flatten the undersurface of the acromion by first creating a trough along the lateral border of the acromion approximately 2-3 mm deep and connecting that trough with a perpendicular line to the posterior edge of the acromioclavicular (AC) joint.  This “orientation trough” was approximately 2 mm deep.  The scope was then changed to the lateral portal and the power equipment to the posterior portal.  The undersurface of the acromion was flattened completely removing approximately 6 mm of subacromial spur from the anterior edge of the acromion.  This was tapered to the surface anteriorly and was completely flat back to the posterior edge of the AC joint connecting our previously placed “orientation trough”.  The arthroscope was then reinserted into the posterior portal where further confirmation of a completely flat anterior subacromial bony surface was confirmed.    

LEFT SHOULDER MUMFORD PROCEDURE (ARTHROSCOPIC DISTAL CLAVICLE RESECTION):   
The electrical surgical tool was used to transect, morselize, and remove capsule and soft tissues from beneath the AC joint.  The shaver was also used to remove soft tissue debris.  The coracoclavicular ligament was identified and preserved on the undersurface of the clavicle.  Once soft tissue was removed from the end of the distal clavicle, the bur was used to resect 10 mm of bone from the distal clavicle.  Care was taken to insert the bur through the anterior portal to ensure adequate resection of the superior aspect of the distal clavicle as well.  A windshield wiper technique was employed to resect the distal clavicle through the anterior portal moving from anterior to posterior while sweeping in a windshield wiper motion from superior to inferior. Care was made to try and preserve the superior acromioclavicular ligaments which were left intact.  This was deemed to be an adequate resection.  The joint was then copiously irrigated with saline solution.  

LEFT SHOULDER ALL-ARTHROSCOPIC ROTATOR CUFF TENDON REPAIR:  
Please refer to the above paragraph under “Findings” whereby details of all arthroscopic rotator cuff repair are described.  

LEFT SHOULDER APPLICATION MICROFRACTURE TECHNIQUE TO CREATE MARROW VENTS TO THE GREATER TUBEROSITY AND TO STIMULATE BONE-TENDON HEALING RESPONSE KNOWN AS CRIMSON DUVET:
Microfracture technique was applied to the greater tuberosity to try to stimulate bone-tendon healing through marrow vents placed using microfracture pick, separating the holes by about 3 mm or so.   

The arthroscope and all instruments were removed. Arthroscopic portals were closed with horizontal nylon mattress ligatures.   

The subacromial bursa was injected with 20 cc 0.5% plain Ropivacaine. A bulky dressing was placed. 

The patient was awakened and taken to postanesthesia recovery in stable condition following an uneventful procedure. 


Thanks again!

Debbie-CPC-A
NW FL Surgery Center


----------



## OCD_coder (Dec 19, 2012)

The shoulder doesn't have different compartments like the knee.   

If you look at the AAOS or Zupko and Associates website for shoulder coding information, it will make much better sense when you need to process Op Report information.  If you send me your private email address to my personal address below, I will send you a Job Aid that I have shared with many orthopedic coders for shoulder coding.

NOTE:  Please email me privately on the AAPC website and I will gladly send anyone a copy of the Job Aid.

** Do not leave your email address here as I do not monitor this posting **


----------



## kathy a (Dec 31, 2012)

Hi Michelle..I have had to learn Ortho Coding on my own as I was thrown into the position. Can you send me the template or any useful info, or tell me if there is any good books or info out there that I can obtain? Thanks -my email is pjandkath@comcast.net.
Kathy Albert,CPC


----------



## nabernhardt (Jan 1, 2013)

would  it be possible to have a copy of the job aide too please.  my email address is nbernhardt@sidneyrmc.com. thank you.


----------



## dwmt1 (Jan 3, 2013)

I am trying to find my way through this mess myself.  Would you be able to send that job aide to my email at dwoolcock@oali.net?  Thank you


----------



## amy_mousie (Jan 14, 2013)

*ortho asst*

would appreciate any assistance also  mousie1227@gmail.com
Thanks. Amy


----------



## twosmek (Jan 17, 2013)

If you could send that to me as well, I would much appreciate it. Any help is helpful.
twosmek@slhduluth.com
Thanks


----------



## lfox (Jan 22, 2013)

I too would appreciate receiving the job aid for shoulder coding.
Thank you.
llfoxxx@msn.com


----------



## donniruth (Aug 9, 2013)

Could I get a copy of the job aid also.  My email is donni.whatley@utcclinics.com
thanks


----------



## gd100 (Aug 9, 2013)

I'm stuck and stressed. GraceDonovan100@gmail.com


----------



## Acctcoder (Sep 5, 2013)

*copy of job aid*

could I also get a copy of job aid for shoulder surgery?  my email is bspencer@woh.rr.com.  Thanks!


----------



## kellit21 (Sep 5, 2013)

if you are willing to send the job aide to me as well it would be greatly appreciated!!
ktaber@upstateoa.com


----------



## cwilson3333 (Sep 9, 2013)

*shoulder aide*

Can you forward a copy of the shoulder aide to me?

Thank you,
cw.lmg@hotmail.com


----------



## DanaHopkins (Sep 13, 2013)

If you still have a copy of this, can you please send one to me as well?  I'm working on one right now.  dhopkins@acssurgeons.com

Greatly appreciated!
Dana


----------



## rblanton (Sep 23, 2013)

I would also like a copy of the job aid.  My email is rblanton@medquestmail.com.  Thank you!


----------



## klbecker (Oct 10, 2013)

Could you also send me the job aid for shoulder surgery.  I would greatly appreciate it!  koswald@chs-mi.com
Thanks!!


----------



## adown999 (Oct 11, 2013)

Could you also send me the job aid for shoulder surgery. I would greatly appreciate 
billing@dallaslimbrestoration.com


----------



## skorkfranks (Oct 11, 2013)

May I also get a copy of the job aid? Thanks. judith.franks@uphs.upenn.edu


----------



## Jennae929 (Jun 5, 2014)

Can someone send me a copy of the job aid for shoulder coding? Jennaelasen@gmail.com
Thank you!!!!!


----------



## DOVERRED (Jun 5, 2014)

hi could you sent the job aid for shoulder surgery coding to doverred@yahoo.com  thank you very much


----------



## jhaleycoder (Sep 4, 2019)

Hi-- I may be late to the party.. haha but can  someone please email me the job aid for shoulder surgery coding JacquelineM@orthocs.com  Thank You So MUCH!!


----------

