# New to this - please help me code this;



## lblanchette (Apr 22, 2009)

Thank you to everyone that responded, this helped me immensely.

Lisa






I should have stated prior, I know what the dxs are, I just want a second opinion or opinions of the cpt codes w/ the modifiers? Would you agree with this or how would you have coded this? Thank you to any or all that respond,

Lisa






PREOPERATIVE DIAGNOSES:
1.  Rotator cuff tear, right shoulder.
2   Acromioclavicular arthritis, right shoulder.

POSTOPERATIVE DIAGNOSES:
1.  Rotator cuff tear, right shoulder.
2.  Acromioclavivular arthritis, right shoulder.
3.  Biceps tendonitis and partial tear, right shoulder.

NAME OF PROCEDURE:
1.  Right shoulder video arthroscopy with arthroscopic debridement synovitis.
2.  Right shoulder biceps tenotomoy
3.  Right shoulder mini open rotator cuff repair with margin convergence and surture anchor technique.
4.  Right shoulder subacromial decompression with acromioplasty and coracoacromial ligament release.
5.  Right shoulder distal clavicle resection.
6.  Application of platelet gel, right shoulder.

INDICATIONS:  A 62 yr old gentleman with pain and discomfort in the right shoulder. Clinical and readiographic evaluation was consistent with a rotator cuff tear with progressive worsening. Due to pain and discomfort, he is brought now for operative intervention. The risks and complicatons including infection, bleeding, neurologic and/or vascular injury were explained and understood.

OPERATIVE FINDINGS:  The patient is known to have moderate tighteness of the shoulder which responded to a gentle manipulation. Intraoperative findings included synovitis, fraying and swelling of the biceps with flattening in the bicipital groove, a fragmented rotator cuff tear with calcium deposition as well as AC arthritis. 

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed under scalene block by Anesthesia and then brought to the operating room and placed under general endotracheal anesthesia. Thea patient was on a spider table with bony prominences padded. The right shoulder and upper extremity were prepped and draped in the usual sterile fashion for upper extremity shoulder surgery. The patient received preoperative antibiotics. Gentle manipulation of the shoulder was done given the tightness of the shoulder. His forward flexion went from approximately 130 degrees to 175 degrees. External rotation improvedwith this manipulation as well. Next glenohumeral joint was infiltrated with saline and epinephrine solution as well as subacromial space, anatomical landmarks were markes. Posterior portal was established, glenohumeral arthroscopy was begun, he was noted to have some bleeding from the manipulation as welll as moderate synovitis. He was noted to have erythema and swelling of the biceps. Subscap was intact, subacromial space was entered, an elliptical tear of the rotator cuff was notes, biceps was visualized through this. Anterior deltoid was detached off the acromion and anterior inferior one third acromioplasty was performed smoothing the undersurface of the acromion. Moderate bursitis was noted, bursectomy was performed, debrided frayed edge of the rotator cuff as well as some nonviable tissue. Debrided the lateral edge of the tuberosity where some remaining stump and tissue was there to create a trough, a healthy boney trough. Next side-to-side sutures were repaired to basically convert a margin convergence repair, placed 2 suture anchors 1 cm apart to get the anterior and posterior flaps. There still was some tension after repair and I did have a short arm mildly abducted to take tension off and was able to put additionals FiberWire sutures to reinforce the side-to-side repair. The repair was together although the conjoined portion still appeared to gave some abnormal tissue. It should be notes that given the flattening of the biceps I did do biceps tenotomy at the insertion at the superior aspect of the glenoid and I left the biceps retract with the slump and tissue. Next, distal clavicle is ecposed and 1 distal cm and half the clavicle was resected. Antibiotic irrigation solution was used. Deltoid was then repaired through bone onto the acromion and the deltoid trapozial and deltoid fascial repaired. Platelet gel was then placed in the subacromial space over the repair and portals. Sterile bulky bandage was applied, the patient was placed in an abduction splint, awakened, extubated and returned to his cart and then the recovery room in stable condition having tolerated the procedure well. Sponge and needle counts were correct.  

I don't totally agree with what the provider billed: 23120 51 59, 23405 51, 23412, 23415 51 59, 29822 51 59- * PLEASE HELP, 

THANKS,
LISA*


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## nyyankees (Apr 22, 2009)

what I saw:

29827      - RCR scope
29826-51  Subacromial decompression
29824-51  Claivicle resection
29999       biceps tenotomy

I only saw scope procedures..not open. Platlet gel is inclusive with RCR. Anyone else?


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## etenndixiechick (Apr 23, 2009)

*I agree*

I agree with nyyankees answer.  I didn't see anything either in op note to indicated open procedures.


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## CrysLednum (Apr 23, 2009)

I agree with the arthro codes - no indication that procedures were done open. And yes, I agree, the platelet gel is included too!


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## coderguy1939 (Apr 27, 2009)

The only portal I see being established in the report is in the posterior glenohumeral joint.  The surgeon states that he enters the subacromial space but he doesn't say how.  No portal or incision is mentioned and that is the only way you'll be able to tell if he did a mini-open or an arthroscopic repair.  My feeling is that you need to go back to the doctor for some clarification.


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## mbort (Apr 28, 2009)

I'm with coderguy on this.  Since he is stating that he did some of these procedures open, I would definitely take it to him and ask "Where's the documentation".  

Mary, CPC, COSC


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