# Total shoulder replacement WITH Biceps tenodesis



## Ccgerson (Aug 30, 2016)

Can 23472 and 23430 both be reported for this surgery?  There is an edit, however in reading several articles, they both can be reported under certain circumstances.  It looks like two incisions were made, I'm not sure if that's enough to justify both codes.  Thank you!

A deltopectoral approach was used. The cephalic vein was identified and retracted laterally with the deltoid. The deltopectoral interval was opened down through the clavipectoral fascia. The conjoined tendon was retracted medially and the deltoid was retracted laterally. The extra nerve was identified and protected. A biceps tenodesis was performed in situ using #2 FiberWire suture. A longitudinal incision was made in the subscapularis tendon leaving a small cuff of lateral tissue for repair. The tendon was sutured tagged. The rotator cuff interval was opened slightly. With the axillary nerve being protected digitally, the capsule was released inferiorly off the humeral head. The biceps tendon was transected at the entrance into the glenohumeral joint and that area was scarified. The humeral head was exposed with straight retractors posteriorly and inferiorly along the superior double angle retractor. The humeral head was cut using an reciprocating saw after a template was used to mark the cut. The cut was made according to the patient's anatomic axis. A proximal humeral protector was placed on the bone followed by a Sonnabend retractor posteriorly and a 3 prong retractor anteriorly. The glenoid was nicely exposed and the biceps stump and labrum was excised with the Bovie circumferentially. A 40 mm trial glenoid was placed on and the central guidewire was drilled. Once the position was optimal the low profile reamers were used followed by a hand reamer followed by the central anchor peg drill. The anchor peg template was then used to place the superior and 2 inferior local drill sites. The 40 mm trial anchor peg glenoid was placed and found to be acceptable. Cement was mixed on the back table and the glenoid was prepared using pulse lavage fluid containing bacitracin along with epinephrine-soaked pledgets for the lug holes. Once the cement was ready it was placed into tuberculin syringes and injected into the lug holes. The central peg of the anchor peg glenoid component was packed with bone autograft around the fins and the implant was then placed and held securely until cement hardened. Attention was turned back to the proximal humerus where the hand reamers were used up to a size 8 followed by broaches up to a size 8. A 44 x 21 mm eccentric head was chosen to be most acceptable. Trial components removed and the bone was prepared with pulsatile should continue bacitracin. A pressfit size 8 humeral stem was placed followed by the 44 x 21 mm eccentric humeral head. The implant was impacted into final position. Final range of motion was checked and acceptable.


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## golymom (Aug 30, 2016)

AAOS considers a biceps tenodesis separately reportable when performing a total shoulder however it is bundled in CCI so would not be reportable to Medicare or any government payors or anyone following Medicare CCI.

I however do not see documentation of the tenodesis.  I see him cutting it which he would to do the TSA but I don't then see the tendon being reattached let alone to a different location.  Also do you have a diagnosis for the biceps pathology?


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## Ccgerson (Aug 30, 2016)

*TSA/ biceps tenodesis/ Thank you! Another question regarding your reply*

First of all, thank you so much for your help.  I've just been coding for 10 months now at an orthopedic practice, and have alot of questions.
You're right,  there's no description of the tenodesis.  And there's no diagnosis for biceps pathology.  If there were, I supposes I'd ask him if he did in fact do a tenodesis and if so, would need to edit the OP note.  But since there's no supporting diagnosis AND it's Freedom Blue insurance, I'll only bill for the TSA.
I do have another case, although this is also MCR insurance, so I wouldn't be able to bill both codes.  But let's pretend it's a commericial carrier, does this documentation below justify 23430 in your opinion?  The only diagnosis in the OP note and H&P is rotator cuff tear arthopathy.  Procedure was reverse TSA and biceps tenodesis. 

"There was complete loss of rotator cuff attatchment in the entire supraspinatus and most of the infraspinatus. The biceps tendon was tenodesed in situ in the bicipital groove using #2 FiberWire suture"


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