# Expert shoulder scope coder please!



## smcbroom (Nov 25, 2008)

So, I wanted to get someone's opinion regarding the 29806 & 29807 codes and whether you feel they warrant being used together in this scenario?  It looks to me like it does but before I went any further I wanted to see what anyone else thought.  So far, I have it coded this way.

29823
29819
29806
29807
29826

I have not appended 59 modifiers as of yet.  I work at an ASC & it's a commercial payer.


PREOPERATIVE DIAGNOSIS:
Left shoulder Bankart lesion and loose bodies.

POSTOPERATIVE DIAGNOSES:
1.  Left shoulder anterior Bankart lesion.
2.  Type II superior labrum anterior to posterior lesion.
3.  Multiple anterior loose bodies.
4.  Degenerative posterior labral tear.
5.  Partial-thickness supraspinatus tear.
6.  Grade III chondrosis of posterior and superior humeral head and anterior glenoid.

PROCEDURES PERFORMED:
1.  Left shoulder arthroscopy with debridement of anterior, superior, and posterior labrum, supraspinatus, and bursa.
2.  Loose body removal x3.
3.  Anterior capsule labral repair.
4.  Superior labrum anterior to posterior repair.
5.  Subacromial decompression.


iNDICATIONS:  
this is a gentleman who sustained an abduction external rotation injury to the left shoulder three years ago.  He has had ongoing popping and pain in the shoulder.  He has evidence of loose bodies and an anterior labral tear.  He is indicated for arthroscopic repair.

FINDINGS:
On examination he had increased external rotation both at the sides and in 90 degrees of abduction.  There was some increased anterior translation.  Arthroscopic examination of the glenohumeral joint reveals an anterior Bankart lesion with detachment of the anterior labrum extending from approximately the 7 o'clock position anteroinferiorly up to the superior labrum.  This extended into a type II SLAP lesion at the superior labrum with instability of the biceps anchor.  Posteriorly, there was degenerative fraying of the labrum but no pathologic detachment.  There was significant chondrosis of the anterior third of the glenoid.  The subscapularis was intact.  The biceps was intact and was stable within the groove.  There was a partial-thickness underside tear of the supraspinatus.  The infraspinatus was intact.  There was significant damage to the articular cartilage at the superior and posterior edge of the humeral head consistent with the chondral lesion there at the time of the injury.  Examination of the subacromial space revealed extensive thickening of the bursa.  There were no bursal side cuff tears.  There was a small focal anterior acromial hook.  In addition, three large loose bodies were found in the subscapularis bursa.  The two largest measured more than 1 cm in diameter and the third was just under 1 cm in diameter.

PROCEDURE IN DETAIL:
Following induction of general anesthesia, the patient was placed in the lateral decubitus position with the left shoulder up.  The left shoulder and upper extremity were prepped and draped in the usual fashion and suspended from 8-pound longitudinal traction.  Intermittent lateral traction was also used.

Standard posterior, anterior, lateral, and anteroinferior portals were established and diagnostic arthroscopy was performed with the findings as above.  The anterosuperior portal was extended and a grasper was used to remove the three large anterior loose bodies from the subscapularis bursa.  The shaver was used to debride the anterior, superior, and posterior labrum as well as the underside of the supraspinatus and the fibrillated articular cartilage on the glenoid and the humeral head.  The shaver was used to freshen the glenoid neck anteriorly and superiorly and preparation for the repair.  The Bankart repair was done first.  A working cannula was placed anteroinferiorly.  A lasso was used to pass FiberStick cinch stitch to the 7 o'clock position on the anteroinferior capsule and labrum.  This was fixed with a PushLock placed at the 8 o'clock position on the anterior glenoid.

Next, another cinch stitch was placed through the middle glenohumeral ligament and anterior labrum and advanced up to approximately 9:30 position.  Next, the working cannula was placed anterosuperiorly.  A cinch stitch was placed through the labrum just anterior to the biceps anchor and the PushLock was placed to repair the anterior portion of the SLAP lesion.  Next, 5-mm cannula was placed laterally through the rotator cuff to the posterior SLAP repair.  A lasso was used to place the cinch stitch through the labrum posterior to the biceps anchor and this was repaired appropriately to the posterosuperior glenoid.  This provided good solid repair of the SLAP lesion and the anterior labrum and capsule.

Next, the subacromial space was entered.  Bursa was resected with the Vulcan and shaver.  The coracoacromial ligament was released from the anterior acromion and a small anterior acromial hook was removed with the shaver leaving a smooth flat undersurface to the acromion.


The arthroscope was withdrawn.  The portals were closed with nylon sutures and 30 cc of 0.25% Marcaine with epinephrine was instilled into the subacromial space.  A sterile dressing was applied followed by a sling.  The patient was awakened and extubated in the operating room and transferred to recovery room in stable condition.

Any help would be appreciated!


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## mbort (Nov 25, 2008)

smcbroom said:


> So, I wanted to get someone's opinion regarding the 29806 & 29807 codes and whether you feel they warrant being used together in this scenario?  It looks to me like it does but before I went any further I wanted to see what anyone else thought.  So far, I have it coded this way.
> 
> 29823
> 29819
> ...




You did great!! (dont forget the C1713)


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## smcbroom (Nov 25, 2008)

Thanks again Mary!  It's good to get reassurance sometimes, especially when I'm my only source here at work.  I thought that the codes were correct but then you start to doubt yourself especially when there are so many!!

Have a good Thanksgiving Holiday to you and fellow coders everywhere!!


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## BFAITHFUL (Nov 25, 2008)

I would not code cpt 29823 as it is bundled into 29806.  I would not use modifier 59 to unbundle this either.  bundle edits and CCI edits also apply to ASC's.  I would bill 29807, 29806-59, 29826 & 29819-59 because size of loose body is documented, it can be billed separately according to AAOS and CPT assistant.


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