# shoulder replacement with glenoid grafting



## esimonsen (Sep 8, 2017)

Hi friends,
I work with some shoulder specialists who are disagreeing about if the glenoid grafting can be separately reported with their shoulders.  
When doing a shoulder replacement they sometimes will do some grafting to the glenoid in order for the prosthesis to sit better.  I was thinking this would be considered inclusive in the replacement, but they believe that this should be separately reportable as it is not a technique all doctors do, and is more work.  What do ya'll think?  

I was thinking of just 23472 but the doc wants to bill 23472 with 20902.  Is this reasonable, or could he bill 23472-22???  

I am really hoping to find an article/instruction I can refer them to.  They don't believe me unless I have it explicitly in writing.



Operative Report 

PREOPERATIVE DIAGNOSIS:  Right shoulder osteoarthritis. 

POSTOPERATIVE DIAGNOSIS:  Right shoulder osteoarthritis. 

PROCEDURE PERFORMED:  Right anatomic total shoulder, lesser tuberosity osteotomy, 
circumferential capsular release, bone graft to glenoid and biceps tenodesis. 

PROCEDURE:  In the preoperative holding area, informed consent was again 
obtained.  Patient was taken to the operating room door, identification was 
confirmed.  She was placed supine on the operating room table and after 
adequate vital sign monitoring a regional anesthetic was applied by the 
attending anesthesiologist.  The right upper extremity was then prepped and 
draped in the usual sterile fashion and general anesthesia was induced. 
Time-out procedure confirmed the right shoulder was the appropriate operative 
site and preoperative antibiotics given prior to the initiation of the 
procedure.  A deltopectoral incision was then taken through skin and soft 
tissue.  The deltoid as well as the cephalic vein were taken laterally and 
the pectorals major taken medially.  Subdeltoid and subcoracoid spaces were 
then freed.  The anterior circumflex humeral vessels were then tied and 
cauterized.  The rotator interval was then opened and the long head of the 
biceps was tenodesed with a #2 ForceFiber suture to the top of the pectoralis 
major.  The biceps was then released and the bicipital groove was then 
cleaned and prepared for a lesser tuberosity osteotomy.  A lesser tuberosity 
osteotomy was then performed.  The upper outer corner was then tagged with #2 
ForceFiber suture.  A circumferential humeral release was then performed, 
dislocating the humerus out of the wound.  The rotator cuff was inspected at 
this time and noted to be full, intact and of normal thickness.  A rongeur 
was then used to remove the significant inferior humeral osteophyte.  A ring 
cutting guide was then applied to the humerus and the humeral head resection 
was then performed.  The bone quality at the humeral head resection was then 
assessed and noted to be adequate.  A centralizing wire was then placed using 
the guide and the simplicity nucleus was then prepared and then placed in 
trial fashion.  A head cup protector was then applied and our attention 
shifted to the glenoid.  A circumferential release was then performed on the 
glenoid including removing the humeral capsule as well as the scarred and 
hypertrophied labrum.  The glenoid was then sized for a size 35 small, 
assessing the backside curvature.  A guidewire was then placed using the 0 
degree guide and fully sunk into the native glenoid.  The glenoid was then 
prepared.   Care was taken to not perforate the subchondral bone.  The 
central post was then drilled and the PEG guide was then applied.  The 
peripheral pegs were then all drilled to their full depth in the PEG guide 
and pegs were then removed.  The glenoid was then copiously irrigated with 
pulsatile lavage.  Cement was placed in each of the outer pegs.  Bone graft 
was then harvested from the humeral head and placed in the fins of the 
Quarter-Lock glenoid.  The glenoid was then impacted into place and fully 
seated.  At this time, the humeral head was brought back into the wound and 
used to compress the glenoid component onto the native glenoid.  The head 
trials were then applied and a 46 mm head was noted to be appropriate.  The 
trial components were then removed from the humerus and the final Simplicity 
nucleus was then impacted into place.  It had excellent and stable fit.  A 
final 46 head was then applied to the Morse taper and the whole construct was 
then malleted into place and fully seated.  Three #2 ForceFiber sutures were 
then placed in a loop fashion through the lesser tuberosity using a drill and 
a Hewson suture passer.  These were then used to perform a lesser tuberosity 
osteotomy repair using racking hitch sutures.  The rotator interval was also 
closed using #2 ForceFiber suture; 500 mg of vancomycin powder was then 
placed into the wound before the rotator interval was closed as well as 
before the lesser tuberosity osteotomy was replaced.  Once the rotator 
interval had been closed completely, the pulsatile lavage was then used again 
to copiously irrigate the shoulder.  A layered closure was then performed, 
followed by a sterile dressing.  Patient was awoken from anesthesia and 
transferred to recovery in stable condition.  The attending surgeon was 
present and scrubbed throughout the entirety of the case.  All needle and 
sharp counts were correct at the end of the case.


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## Orthocoderpgu (Sep 13, 2017)

*In this case obtaining the bone graft is bundled*

I code a lot of total shoulders too and my docs don't build up the glenoid very often.  

If you obtain the bone graft from the same surgical area, then it's included with the TSA.

If the graft is taken from a distant site, which creates a new surgical field and opening, then you would bill the grafting separately. 

In this case they obtained the bone graft material from the humeral head. 

If you have access to Code-X it states that the graft has to be taken from a distant site in order to bill for it separately.


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