Orthopedic Coding Alert

Question: For a patient diagnosed with bicipital tendonitis and left shoulder impingement, our surgeon did an arthroscopic left shoulder biceps tenotomy and bursectomy.

The operative note reads as follows:

"A posterior portal was established. Blunt trocar and cannula were introduced into the left shoulder. The arthrscope was brought through the cannula as was inflow using the Dyonics pump and normal saline. Examination revealed there was about 30% to 40% tear of the biceps tendon at its root. Using a wand through an anterior portal and biceps tenotomy was performed. The humeral head and glenoid were smooth. There was a partial articular surface tear of the rotator cuff that was probably 10% of thickness."

"The subacromial space was entered with an arthroscope posteriorly. The lateral portal was established. There was thick bursa, which was excised. The shoulder was then put through a range of motion and once the soft tissue was removed from the under surface of the acromion, there was no impingement. An acromioplasty was not performed. The rotator cuff was inspected and palpated. No tears were found. Hemostasis was obtained using the ArthroCare wand. The wounds were closed with simple sutures of 3-0 nylon. A soft dressing was applied. The arm was placed in a sling. The patient tolerated the procedure well and left the operating room in satisfactory condition."

How do we report this condition?

New York Subscriber

Answer: You report biceps tenotomy with unlisted code 299999 (Unlisted procedure, arthroscopy). Since your surgeon is not doing an acromioplasty, code 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e. arch] release, when performed (List separately in addition to code for primary procedure]) does not apply. Confirm the extent of debridement and report 29822 (Arthroscopy, shoulder, surgical; debridement, limited) or 29823 (Arthroscopy, shoulder, surgical; debridement, extensive). Both the AMA and AAOS have recently published reporting advice that deems it appropriate to report a debridement codes under these circumstances.