Orthopedic Coding Alert

Question: I have a report specifying a combined approach McLaughlin procedure for a patient with a reverse Hill-Sachs lesion. Which CPT and ICD-9 codes should I report?

Alabama Subscriber

Answer: In a combined approach, orthopedists perform the surgery with a posterior capsulorrhaphy through combined anterior (McLaughlin) and posterior (capsulorrhaphy) approaches.

Experts suggest reporting 23465 (Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block) for the combined approach, although some payers may allow you to report 23395 (Muscle transfer, any type, shoulder or upper arm; single) as well.

Tip: If the surgeon documents an anterior approach alone, you should report 23395 without 23465.

For the diagnosis, you should report 718.31 (Recurrent dislocation of joint; shoulder region).

A Hill-Sachs lesion can occur when a shoulder dislocates anteriorly, and the humerus- smooth cartilage surface hits the scapula's rim. A reverse Hill-Sachs lesion occurs when the shoulder dislocates posteriorly.

The procedure: Surgeons perform McLaughlin procedures to treat posterior dislocating shoulders. During the operation, the surgeon performs a tendon transfer by moving the subscapularis tendon from its location on the lesser tuberosity into the reverse Hill-Sachs defect.