Orthopedic Coding Alert

Not every SLAP lesion debridement claim will warrant separately reporting 29822 If you bemoan coding arthroscopic shoulder surgeries - particularly those that include separate SLAP lesion debridement - a few minutes brushing up on the basics could be just what you need to improve your SAD coding skills.
 
Take a look at the following arthroscopic subacromial decompression (SAD) operative note and review our experts' coding recommendations.
 
Procedure Overview: See What the Surgeon Performed Here's a quick synopsis: A 37-year-old male patient with left shoulder pain has severe acromioclavicular osteoarthrosis (715.91), impingement and tendonitis (726.2). The orthopedic surgeon performed left shoulder arthroscopy, arthroscopic SAD, an arthroscopic Mumford procedure, and a bilateral shoulder examination.
 
Additional Procedure: The surgeon also debrided a type I superior labrum anterior and posterior (SLAP) lesion. Operative Note: Trace the Surgeon's Work The pertinent details from the operative report: The surgeon established standard anterior, posterior and lateral arthroscopic portals. On the glenoid side, the patient had a 4-mm, grade-2B lesion. The central aspect of the glenoid was without any loose flaps, circumferentially. No evidence of any loose bodies. Patient had a negative drive-through sign, negative peel-back sign. Biceps tendon and biceps anchor intact. Patient had a type I SLAP. This was debrided with arthroscopic shaver. Patient's rotator cuff and subscapularis were intact; labrum otherwise intact.
 
We carefully inspected the labrum from both posterior and anterior portals and saw no evidence of posterior labral tear or posterior capsular tear. Patient had a patulous axillary recess. No notable synovitis superiorly. We then went to the subacromial space. Dense bursal adhesions and tissue were demonstrated. We debrided this out with arthroscopic shaver and ArthroCare device. Patient had moderate subacromial prominence. We performed an arthroscopic subacromial decompression from both portals. Confirmed from both portals. Excellent decompression, including the release of the CA ligament. AC joint with osteoarthrosis and inferior osteophytes.
 
We performed a distal clavicle resection of 8-9 mm, preserving the ligaments. All debris removed. Irrigated all material from the subacromial space. Carefully inspected the rotator cuff from the bursal side and found no evidence of tearing there. Closed with 2-0 nylon sutures. Coding Advice: Follow These 4 Steps Step 1: Code the Main Procedure. First report 29826-LT (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; Left side). You should link this code with 726.2 (Rotator cuff syndrome of shoulder and allied disorders; other specified disorders), says consultant Annette Grady CPC, CPC-H, with Eide Bailly in Bismarck, N.D.
 
Step 2: Code the Arthroscopic Mumford Procedure. You should report 29824-LT (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure]) to represent the surgeon's work performing the distal clavicle resection. You should link this procedure to 715.91 (Osteoarthrosis, [...]