Orthopedic Coding Alert

Question: What is the correct diagnosis code for the following (exploratory) operative findings? A frayed and detached superior anterior labrum with detachment of the junction of the anterior superior and anterior portion of the labrum and about 90 percent detachment of the anterior aspect of the labrum right at the biceps tendon anchor. Some fraying of the posterior superior labrum but no detachment and no detachment of the biceps tendon anchor itself. Some synovitis especially anteriorly and superiorly. No evidence of any rotator cuff tear. The middle glenohumeral ligament was somewhat frayed and the patient did appear to have some subtle laxity anteriorly, increased from the opposite side both on exam under anesthesia and when viewing through the arthroscope. The remainder of the patients labrum appeared normal. The subacromial space appeared without any significant synovitis, and the rotator cuff looked intact looking at it superiorly.

Anonymous South Carolina Subscriber

Answer: Blair C. Filler, MD, FACS, director of Medical Education at Los Angeles Orthopedic Hospital, says, If there is shoulder joint derangement with laxity, use ICD code 718.81 (other joint derangement, not elsewhere classified, shoulder region). Otherwise use 719.91 (unspecified disorder of joint; shoulder region). There are no specific codes for labral lesions.

Some experts also recommend adding the diagnosis codes for bursitis, shoulder (726.10, disorders of bursae and tendons in shoulder region, unspecified) and synovitis (719.21, villondular synovitis; shoulder region).

Susan Callaway-Stradley, CPC, CCS-P, says although the computer will only scan the first, main diagnosis code listed, it is a good idea to list all the codes that apply. She explains if the payer challenges a claim, having all the applicable diagnoses on record can help with an appeal.