# CPT code for arthroscopic decompression of the cyst in the spinoglenoid notch



## oceania (Aug 26, 2015)

I would like someone else's opinion on this procedure and diagnosis codes. I've included the OP note. 

PREOPERATIVE DIAGNOSES:                                                       

1.  Left shoulder rotator cuff tear.                                          

2.  Left shoulder labral tearing and proximal biceps tendon tearing.          

3.  Left shoulder impingement.                                                

4.  Left shoulder cyst of the spinoglenoid notch.                             



POSTOPERATIVE DIAGNOSES:                                                      

1.  Left shoulder rotator cuff tear.                                          

2.  Left shoulder labral tearing and proximal biceps tendon tearing.          

3.  Left shoulder impingement.                                                

4.  Left shoulder cyst of the spinoglenoid notch.                             



OPERATIONS:                                                                   

1.  Left shoulder arthroscopic rotator cuff repair.                           

2.  Left shoulder arthroscopic decompression of the cyst in the spinoglenoid  

notch.                                                                        

3.  Left shoulder arthroscopic subacromial decompression and acromioplasty.   

4.  Left shoulder arthroscopic debridement of extensive labral tearing.       

5.  Left shoulder mini open subpectoral biceps tenodesis performed as a       

separate procedure.                                                           



ANESTHESIA:  Regional, supplemented with general.                             



BLOOD LOSS:  Minimal.                                                         



BLOOD REPLACEMENT:  None.                                                     



INTRAVENOUS FLUIDS:  Please see the anesthesia record.                        



WOUND:  Clean.                                                                



COMPLICATIONS:  None.                                                         



DRAINS AND PACKING:  None.                                                    



IMPLANTS:  Please see the hospital record for exact implant specifications,   

but, briefly, 2 separate 3.5 mm titanium Arthrex corkscrew anchors were used  

as a medial row construct of the rotator cuff repair and these were backed up 

laterally to a 4.75 mm PEEK Arthrex SwiveLock anchor to complete a            

transosseous equivalent double row construct.  An Arthrex biceps button system

was used for the biceps tenodesis.                                            



INDICATIONS FOR SURGERY:  Please see my accompanying history/consultation     

dictations for details, but I explained the anatomy and pathophysiology       

involved with the above diagnosis, and recommended surgical intervention as a 

treatment option.  I explained the technical aspect of the procedure and the  

post-operative rehabilitation program.  I explained risks and benefits as well

as alternatives to surgery, with risks including infection, neurovascular     

injury, neuropraxia, the possibility of future surgery, limb length           

inequality, malrotation, nonunion, malunion, post-traumatic pain, arthritis,  

weakness, and stiffness, and medical and cardiac complications of anesthesia, 

and DVT.  I explained clearly that the surgery would be unlikely to completely

eliminate all pain.  All these concepts were reviewed and all questions were  

answered. Informed consent was obtained, and I marked the operative site in   

the preoperative holding area.                                                



DESCRIPTION OF PROCEDURE:  At this point, as viewing the labral tearing from  

the lateral portal, an extensive debridement was used with the arthroscopic   

shaver and radiofrequency device of substantial tearing in the superior and   

posterior aspect of the labrum.  Frayed tissue was debrided down to a stable  

base and no remnant tearing was seen.                                         



Regional anesthesia was achieved by the anesthesia team in the preoperative   

holding area and the patient was transported from there to the operating room.

The patient was gently                                                        

transferred to the hospital operating room table, where supplemental general  

anesthesia was achieved by the anesthesia team.  The patient was then placed  

in a well-padded beach chair position, where all bony prominences were well   

padded. Preoperative antibiotics were administered to the patient prior to any

operative incision and the shoulder was prepped and draped in standard sterile

fashion for shoulder arthroscopy.  A timeout was called and confirmed.        



At this point, bony landmarks were palpated and marked and a standard         

posterior portal to the shoulder was developed with an 11-blade scalpel.      

Diagnostic arthroscopy ensued.                                                



Survey of the glenohumeral joint showed no significant undue damage to the    

cartilaginous surfaces and a standard anterior working portal was developed   

through the rotator cuff interval using a spinal needle for localization.     

Further survey of the shoulder showed only age-appropriate degenerative       

changes at the subscapularis, but significant tearing of the proximal biceps  

tendon and the SLAP region of the labrum.  Furthermore, a full-thickness tear 

was seen of the supraspinatus tendon.                                         



The above-mentioned pathology was debrided using a combination of an          

arthroscopic scissor, arthroscopic shaver, and radiofrequency device.  Given  

the patient's age, the tearing in the labrum and biceps tendon necessitated a 

biceps tenodesis and the biceps tendon was cut from its attachment on the     

supraglenoid tubercle and this remnant was debrided down to a stable base.    



A lateral working portal was also developed as the degenerative torn          

supraspinatus was debrided as well and arthroscopic bur was used to prepare   

the greater tuberosity as a footprint for rotator cuff repair.                



Attention then turned to the subacromial space, where standard subacromial    

bursectomy was performed.  Furthermore, the undersurface of the acromion was  

found to have significant wear with signs of external impingement and thus a  

formal acromioplasty using an arthroscopic bur in a cutting block technique   

was performed.  Following this portion of the procedure, the shoulder was     

taken through a full range of motion and no external impingement was seen.    



At this point, a correlated surgical treatment based on preoperative findings 

and particularly with the advanced imaging in that an MRI preoperatively      

demonstrating the posterior-superior paralabral cyst extending to the         

spinoglenoid notch.  I, using a mosquito clamp and arthroscopic probe from the

posterior portal, dissected the above-mentioned area and with the help of the 

arthroscopic shaver and using a pituitary for gentle dissection, the cyst was 

approached with the arthroscope and successfully decompressed.  Gelatinous    

fluid was yielded and rinsed via arthroscopic lavage, thus completing the     

decompression of the cyst.  Again, appropriate decompression was performed as 

much as possible through the arthroscope and no indication for open surgery in

this area was seen.                                                           



Attention returned to the rotator cuff and the above-mentioned medial row     

anchors were implanted in standard technique.  A DePuy Mitek suture passer    

device was used to pass horizontal mattress stitches in the appropriate aspect

of the rotator cuff and these were tied down using standard arthroscopic      

knots.  The limbs were locked laterally to the above-mentioned lateral anchor 

and this completed an anatomic repair in double row fashion.  The ends of the 

sutures were cut and a robust anatomic repair was clearly visualized and the  

shoulder was taken through full range of motion without incident.             



The shoulder was rinsed via arthroscopic lavage and attention turned to the   

mini open subpectoral biceps tenodesis.                                       



A mini open incision was made in an anterior axillary fold totally normal with

approximately 4 cm.  Meticulous hemostasis was maintained with Bovie          

electrocautery and dissection ensued to the subpectoral interval and Hohmann  

retractors were placed in that interfold with care to avoid even traction     

injuries to the neurovascular structures including the musculocutaneous nerve 

in particular.  The long head of the biceps tendon was easily identified and  

removed from the wound.  Using the standard Arthrex biceps button technique,  

the appropriate tension and length of the biceps was identified and a #2      

FiberLoop stitch was used to create a locking suture construct in the biceps  

tendon near the musculotendinous junction.  The end of the tendon was removed 

and again confirmed to be significantly degenerative and torn.  The limbs of  

the FiberWire were passed through the button in proper fashion and the        

appropriate location, the biceps groove was once again identified due to      

appropriate tension of the tenodesis.                                         



Using the Arthrex spade drill, a bicortical path was drilled and the anterior 

cortex was reamed with a size 6 reamer.  Meticulous irrigation was used to    

debride the reamed bone for fear of heterotopic ossification and this was     

confirmed.  The button was passed out the posterior cortex and flipped and the

sutures were pulled docking the tendon into the tenodesis site.  Excellent    

dockage of the tendon was clearly visualized and a secure construct was       

obvious.  One of the limbs of the FiberWire was passed through the tendon and 

this was used as post to lock a knot, which was tied with the help of an      

arthroscopic knot pusher.  The end of the sutures were cut and the elbow was  

taken through a full range of motion and a robust secure tenodesis was        

visualized with appropriate tension.                                          



All wounds were thoroughly irrigated with normal saline and the subdermal     

layers were closed with a 3-0 Vicryl suture.  The skin was closed with a      

combination of 3-0 Monocryl suture and Dermabond and a standard sterile       

dressing was applied.  The patient was placed in a shoulder immobilizer and   

anesthesia was discontinued.  The patient was gently taken down from the beach

chair position and transferred to a hospital stretcher and transported to the 

recovery room, where the patient arrived in a hemodynamically stable condition

having tolerated the procedure well.


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## oceania (Aug 28, 2015)

*Please help*

Please help with the CPT code for shoulder arthroscopic decompression of the cyst in the spinoglenoid notch. The office I work in has many difficulties with coding an unlisted code. I just need some back up that an unlisted code would be the best code for this procedure.


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## oceania (Aug 28, 2015)

*Please help*

Please help with the CPT code for shoulder arthroscopic decompression of the cyst in the spinoglenoid notch. The office I work in has many difficulties with coding an unlisted code. I just need some back up that an unlisted code would be the best code for this procedure.


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