# Help with shoulder surgery for re-injury



## peporter (Jun 27, 2009)

Hello Coders, I need some help with this. Surgeon did a coracoclavicular ligament reconstruction and the patient re-injured the shoulder, deforming the shoulder. On the first surgery I used 23552 for the dislocation and ligament repair. I have posted the note for the second surgery. How would the reconstruction and ligament repairs be coded this time?
So far I have 23585, 23120, 20680. Can I use the 23552 again for the AC reduction and ligament repairs? Are there better codes to use? Thanks, Paula in Dublin, Oh


OPERATION
1. Open reconstruction left shoulder, coracoclavicular ligament.
2. Open reconstruction left shoulder, AC ligament.
3. Open treatment left scapula coracoid process fracture with internal
fixation.
4. Left shoulder open distal clavicle excision.
5. Removal of hardware, deep left shoulder.
6. Left shoulder open reduction and internal fixation, AC joint.


An oscillating saw was taken to excise 1-cm of the distal clavicle.
This was removed. The medial aspect the acromion was exposed too. This
would be for later reconstruction of the AC ligaments. Some of the
clavicle medially was exposed as well. The Endo button could be seen.
This was pulled up and the sutures were cut. The biotenodesis screw was
removed before this as well with the screwdriver. Both Endo buttons
were retrieved. The graft was pulled out as well that was within the
Endo button. I did dissect bluntly down to the coracoid process. This
had been fractured off. The button actually pulled through the entire
coracoid base. I did extend the incision down to a deltopectoral
incision for the superior half. Blunt dissection was taken down to the
deltoid. The deltoid was split in line with the interval. The deltoid
was tagged with a Vicryl suture. This would be for later repair. Blunt
dissection was then taken down the coracoid process. The fracture ends
were freshened with a curette. This was reduced anatomically. A
guidewire for the 4-0 cannulated screws were placed to the coracoid and
into the scapula. I used the 2.7-mm drill bit over this.
I then measured the length and this was a 40-mm screw. I chose a 4.0
partially threaded cannulated cancellous screw with a washer. I placed
this in over the wire which compressed and held the coracoid process
anatomically. This was an excellent repair. The wire was removed. I
did pass a suture underneath the base before fixation. This is where I
would pass my graft. I chose a posterior tibial tendon allograft to
reconstruct the coracoclavicular ligaments. Number 2 FiberWire was
taken and a whip stitch was placed to both ends of the graft. The graft
was sized at 6-mm. I passed this underneath the coracoid base using the
suture loop that I had placed previously. I put one end of the graft
through the hole in the clavicle from the prior procedure. I then
drilled a small 3-mm hole at the distal end of the clavicle for
reconstruction of the AC ligaments. I chose a gracilis allograft for
this. Number 2 fiber wires were taken at both ends of this graft and it
was whip stitched. The graft was passed through the distal end of the
clavicle hole with a Houston suture passer. I did choose a 7 hole
Synthes hook plate to help hold down the clavicle where the ligament
healed.
I did choose a 15-mm hook. This was placed on the acromion and over
the grafts on the clavicle and the AC joint was anatomically reduced. A
3.5 fully threaded cortical screw was placed through one of the medial
holes in the plate into the shaft after drilling and measuring to the
appropriate sized length. This pulled the plate to the bone nicely.
This anatomically reduced the distal clavicle. I placed another 3.5
fully-threaded cortical screw next to this. The graft through the
clavicle underneath the coracoid was then tensioned and then tied with a
#2 FiberWire. This had excellent repair. This was reconstruction of
the coracoclavicular ligaments. The excess graft was cut with a
scalpel. I did then place a locking screw through 1 of the holes
medially in the plate through the shaft as well. The locking guide was
then used, drilled and measured to the appropriate size length. The
screw was inserted. I took the graft over the AC joint crossed this
under the top of the acromion. One suture anchor was placed posterior
and 1 was placed superior. The graft was tied down with the suture
anchors.
I used 3.0 bioabsorbable anchors by Arthrex and placed this in after
drilling and then tapping this into place through the guide. Again 1
limb of the graft was placed posterior and 1 was placed superior
creating a reconstruction of the AC ligaments. This was then tied back
on itself and sutured with a #2 FiberWire. The excess graft was trimmed
with the scalpel. The CC and AC ligaments were reconstructed and the
hook plate was there to hold the reduction while these healed. This was
anatomic. The coracoid maintained its fixation. The wound was
copiously irrigated out with normal saline. Vita-Gel soft tissue
autograft was injected deeply. The deltoid was approximated back to the
clavicle through the drill holes. This was done with a #2 FiberWire.
The deltoid was repaired back on itself, as well as the deep fascia with
a #2 FiberWire. This was oversewn with #1 Vicryl. The skin was
approximated with 2-0 Vicryl and then staples placed on the skin. Local
anesthetic was injected. A sterile dressing was applied as well as cold
therapy pack placed over the gown. The arm was placed in an
immobilizer. The patient was then awoken from anesthesia without
complication, and transferred to the post anesthesia care unit in stable
condition.


----------



## lavanyamohan (Jun 28, 2009)

Hi,
I agree with your codes;
But what I feel is:
CPT 20680 is bundled. Can avoid.
CPT 23552 can be coded again. Because this is a new operation.
LM


----------



## jlmmcb (Jun 28, 2009)

I was coming up with the same codes.  I am a student getting ready to go on externship and I am glad that I am heading in the right direction.  For number 6 on your list, could you code 23101 and 23700 or is there a bundled code for that procedure that I am overlooking?


----------



## peporter (Jun 29, 2009)

Thank you coders for your responses. Regarding the last procedure, the 23101 is inclusive according to the AAOS global book and I think the manipulation would also be inclusive. Does anyone agree with that or have comments? Thanks again, Paula


----------

