# Shoulder surgery:  29826 with 29823????



## Desperate Denise (Jun 26, 2010)

Fellow coders:

My boss in one week performed three surgical procedures and coded all three as 29826 and 29823.  In each scenario - two of which are noted below.  The third surgery involved a partial rotator cuff tear that he coded 29823.  So there are three cases all with one diagnosis of impingement syndrome and procedure SAD 29826.   The first op note the patient had glenohumeral arthritis, the second a labral tear and once again the third a rotator cuff tear.  The CSI edits indicate that 29823 is bundled with 29826.   

Any help will be GREATLY appreciated.    Thank you!!! 

FIRST OP-NOTE

 POSTOPERATIVE DIAGNOSIS:
 1.        Left shoulder pain.
 2.        Left shoulder glenohumeral joint arthritis.
 3.        Left shoulder impingement.

 OPERATION PERFORMED:
 1.        Left shoulder arthroscopy.
 2.        Left shoulder glenohumeral joint debridement.
 3.        Left shoulder subacromial decompression.

 The patient was brought into the  preoperative area.   Site  and  side were identified.  There was no interscalene  block administered.  The patient was brought into the operating room and  placed supine  on  the  operating  room  table.   Bony  prominences  were  padded appropriately.   General endotracheal intubation was performed.   She  was then placed in the beach-chair position.  Examination of the left shoulder under anesthesia revealed full passive range of motion in all planes.  The left  upper  extremity was prepped and draped in a sterile fashion.   Bony landmarks   of   the  shoulder  including  posterolateral,   lateral   and anterolateral aspects of the acromion were marked with a marking pen. 
 A  mark  was  then made 2 fingerbreadths down and 2 fingerbreadths  medial
 from the posterolateral aspect of the acromion.  An 18-gauge spinal needle
 was inserted into the glenohumeral joint.  The joint was distended with 60
 mL  of  sterile saline.  An 11-blade scalpel was used to incise the  skin.
 An   arthroscope  was  introduced  into  the  posterior  aspect   of   the
 glenohumeral  joint  and a diagnostic arthroscopy was  begun.   There  was
 evidence  of  grade  4 chondromalacial changes over the  glenoid  surface.
 There  were some grade 2-3 chondromalacial changes over the humeral  head. These were in focal areas.  No evidence of subscapularis muscle tear.  The biceps tendon appeared to be in good condition.  There was some tendinitis of  the rotator cuff but no frank tearing.  No evidence of loose bodies in the axillary pouch.
 An  anterior portal was established using an outside-in technique.  An 18-
 gauge  spinal  needle  was  inserted above  the  superior  border  of  the
 subscapularis.  An 11-blade scalpel was used to incise the skin.   A  7-mm
 cannula  from  Arthrex  was introduced into the glenohumeral  joint.   The
 joint  was  debrided using an arthroscopic shaver.  Once again the  biceps
 tendon was brought into the glenohumeral joint.  There was no evidence  of
 biceps tendon pathology.  The rotator cuff was intact.

 Once  all  intra-articular work was complete, the arthroscope was  removed
 from the glenohumeral joint and introduced into the subacromial space from
 a  posterior  approach.  A lateral portal was established 3 fingerbreadths
 down from the anterolateral aspect of the acromion.  There was evidence of
 bursitis and a bursectomy was performed.  The undersurface of the acromion
 was  cleared of all soft tissue using the arthroscopic shaver as  well  as
 the ArthroCare wand.  The coracoacromial ligament was released.  There was
 evidence of a large subacromial spur.  From a lateral portal using  a  4-0
 acromionizer  bur a subacromial decompression was performed.   Debridement
 of the rotator cuff was performed from the subacromial space.  The arm was
 brought  through  both  internal  and external  rotation.   There  was  no
 evidence of rotator cuff tearing.

 Once  all  subacromial work was complete the arthroscopic  instrumentation
 was  removed from the shoulder. 



SECOND OP NOTE

 POSTOPERATIVE DIAGNOSIS:
 1.        Right shoulder pain.
 2.        Right shoulder labral tear.
 3.        Right shoulder impingement with bursitis.

 OPERATION PERFORMED:
 1.        Right shoulder arthroscopy.
 2.        Right shoulder glenohumeral joint debridement.
 3.        Right shoulder subacromial decompression.


 Site  and  side were identified.  The interscalene block was  administered
 and  he was then brought into the operating room and placed supine on  the
 operating  room  table.   Bony prominences were padded  appropriately  and
 general endotracheal intubation was performed.  He was then placed in  the
 beach-chair position.  Examination of the right shoulder under  anesthesia
 revealed  full  passive range of motion in all planes.   The  right  upper
 extremity  was prepped and draped in sterile fashion.  Bony  landmarks  of
 the  shoulder including posterolateral, lateral, and anterolateral  aspect
 of  the acromion were marked.  The AC joint and the coracoid process  were
 marked  as  well.  Then a mark was made 2 fingerbreadths down,  2  fingers
 medial from the posterolateral aspect of the acromion.  An 18-gauge spinal
 needle  was inserted into the glenohumeral joint.  The joint was distended
 with 60 mL of sterile saline.  An 11-blade scalpel was used to incise  the
 skin.    An  arthroscope  was  introduced  into  the  glenohumeral  joint.
 Diagnostic arthroscopy was begun.  There was no evidence of chondromalacia of the glenoid or humeral surfaces.  There was evidence of superior labral tear fraying.  There was no evidence of subscapularis muscle tear.  Biceps tendon was in good condition.  Supraspinatus tendon was in good condition. Infraspinatus  tendon was in good condition.  There  was  no  evidence  of loose  bodies  within  the  axillary  pouch.   The  anterior  portal   was established using an outside-in technique.  An 18-guage spinal needle  was inserted  above the superior border of the subscapularis muscle.   An  11- blade  scalpel was used to incise the skin.  A 7-mm cannula was introduced in the  glenohumeral joint.  Superior labrum was debrided.  It was felt to be  a  type II SLAP lesion but this was chronic in nature.  Peel  off  was negative.   No  evidence  of fraying, biceps tendon  instability.   Biceps tendon  was  brought into the shoulder.  There was no evidence  of  biceps tendinitis.  Once all intra-articular work was completed, arthroscope  was introduced  into  the  subacromial space.  A lateral  portal  was  made  3
 fingerbreadths down from the anterolateral aspect of the acromion. The  7-
 mm  cannula was introduced into the subacromial space.  There was evidence of   abundant  bursitis.   A  complete  bursectomy  was  performed   using arthroscopic  shaver as well as the ArthroCare wand.  The undersurface  of the  acromion  was  cleared of  all soft tissue. From the  lateral  portal using  4-0  acromionizer bur, a subacromial decompression  was  performed. Once  the  decompression was completed, all bursa was removed out  through the  rotator cuff.  Arm was brought into internal and external  rotations. There was no evidence of rotator cuff tear.  Once all subacromial work was completed,  arthroscope was removed from the shoulder.


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## nyyankees (Jun 28, 2010)

In op-report #2 all I saw a debridement of SLAP tear (840.7) to go with the SAD (29826). I would go with 29826, 29822-59 for the SLAP debridement.

In op-report #1 I would want to know what EXACTLY he debrided in the glenohumeral joint (humeral head, etc) to go along with the RC debridement.

If there is a separate problem (i.e. SLAP tear) that needs to be addressed outside of the SAD (29826) you can capture it. 29822 is usually for 1 soft tissue while 29823 is for multiple soft tissue.

Anyone else?


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## GinaM (Jun 29, 2010)

I do not believe 29823 is inclusive to 29826 check your edits again.


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