# Arthorscopic Shoulder Surgery



## dyoungberg (Dec 19, 2012)

I am very unsure of how to code this surgery.  I've chosen 29806, 29822-59, & 29821-59.  Am I correct in coding this procedure?

PROCEDURE:	
1. 	LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY 
2. 	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH DEBRIDEMENT OF ROTATOR CUFF TENDON AND LABRAL TEARS
3.	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH GLENOHUMERAL SYNOVECTOMY
4.	LEFT SHOULDER OPERATIVE ARTHROSCOPY WITH ALL-ARTHROSCOPIC CAPSULOLABRAL SUTURE PLICATION (CAPSULAR SHIFT)
5.	LEFT SHOULDER DIAGNOSTIC BURSOSCOPY 
6.	LEFT SHOULDER INSERTION INDWELLING PAIN PUMP CATHETER INTO THE SUBACROMIAL SPACE

ANESTHESIA:	GENERAL

IMPLANT: 		NONE

COMPLICATIONS:  	NONE NOTED

EBL: 			MINIMAL 

FINDINGS: 
With the patient asleep, she was found to have evidence of multidirectional instability in an anterior greater than posterior pattern or direction and I was able to get the humeral head to the glenoid rim anteriorly and to near the glenoid rim posteriorly with only mild inferior laxity less than 1 cm that corrected with external rotation of the elbow at the side. Intraarticular findings confirmed similar instability pattern.  

The intraarticular findings revealed normal articular surfaces, normal intraarticular rotator cuff, supraspinatus and infraspinatus, normal biceps tendon.  Biceps  tendon labral attachment had some tearing present from anterior to posterior typical of a SLAP type I lesion, treated by cautery device to debride that with well attached labral remnant seen following debridement.  Normal anatomic variant of a cord-like middle glenohumeral attaching to the biceps tendon anchor associated with absent anterior superior glenoid labrum was identified.  This complex is known as a Buford complex and was actually described by myself in The Journal of Arthroscopy.  The point of that study was to not repair what was, and is, a normal anatomic variant of the cord-like middle glenohumeral ligament.  The intraarticular subscapularis did have some partial tear of approximately 5% that was readily debrided using full radius resector and cautery device.  Patulous capsule was seen anteriorly and posteriorly and the humeral head was seen to be sitting on the anterior inferior glenoid rim at about the 7 o'clock position in this left shoulder.  Some synovitis was seen anteriorly, as well as posteriorly, treated by synovectomy.  A pancapsular suture plication was done to reduce the capsular volume and re-establish a more normal relationship of the humerus to the glenoid and it centered nicely following that pancapsular plication done anteriorly, then posteriorly through separate portals, as described below.  An anatomic reconstruction was achieved.  Drive-through sign was eliminated.  

In the bursa there was noted to be a completely normal appearance of the bursa with normal rotator cuff without any evidence of bursitis or fraying of the coracoacromial ligament.  A pain pump catheter was inserted into the subacromial space under direct visualization for postoperative pain management.

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 examining 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.


ALL-ARTHROSCOPIC CAPSULOLABRAL SUTURE PLICATION (CAPSULAR SHIFT):   Following the arthroscopic evaluation, as described above under “Findings”, the instability pattern was felt to be amenable to an all-arthroscopic capsulolabral suture plication or arthroscopic capsular shift type of procedure. This was accomplished using a similar technique both anteriorly and posteriorly to plicate the capsular tissue in a manner as described herein. Initially, with the scope in the posterior portal, the whisker blade was inserted to perform a light superficial synovectomy of the anterior inferior capsular tissue by lightly debriding this tissue to get a bleeding surface for capsular plication healing purposes.  This was done with care to avoid completely performing synovectomy as this capsular tissue was required in order to perform the plication. Once this was done, the standard operative cannula was switched out for a large working cannula which allowed passage of the Spectrum suture hook from the Linvatec company. Ligature of #1 PDS was then passed and the technique was similar to all sutures that were placed both anteriorly and posteriorly. The technique was to take the suture hook and grasp a pinch of the capsular tissue in the area to be plicated and then this pinch of tissue was then advanced using the suture hook and the suture hook was then inserted into the labral tissue and exited out toward the central portion of the glenoid labrum. The #1 PDS ligature in the suture hook device was then deployed fully into the joint. The suture hook device was removed and the suture was then tied using a Duncan loop with three alternating half-hitches. The idea being to advance the tissues superiorly and centrally toward the glenoid labrum. This allowed a nice plication to occur. In this case, the sutures were placed at the 6:30, 8:30, and 9 o'clock positions in this left shoulder. 

Next, the scope was switched to the anterior portal and a similar technique was utilized to plicate the posterior capsular tissues. Two additional sutures were placed at the 3 and  5 o'clock positions.  At the conclusion of the procedure, excellent restoration of the relationship of the humeral head to glenoid was achieved in a more normal and anatomic manner with much more physiologic stability achieved and elimination of the drive-through sign. 

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 INSERTION OF INDWELLING PAIN PUMP CATHETER INTO THE SUBACROMIAL SPACE:   
An indwelling pain pump catheter was placed into the subacromial space under direct visualization using the arthroscope for direct visualization.  The pain pump was filled with 90 cc 0.5% Ropivacaine without epinephrine. The pain pump catheter was secured with Steri-strips only without sutures.  

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 very much for any help and insight in this procedure!

Happy Holidays!

Debbie, CPC-A
NW FL Surgery Center


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## OCD_coder (Dec 19, 2012)

Per Zupko and Associates who educate the AAOS states that a capsular shift is a debridement.  I am seeing only debridements performed 29823 and a synovectomy   
29821.  They do not bundle per NCCI edits and a mod-59 would not be appropriate.  

I did not look into the code for pain pump placement, but pain control is part of global and I would be inclined to consider that as bundled until I can find more information.  I am very open to other opinions on this part of the surgery.


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