lcole7465
Expert
Ok, so there's a little discussion going on with the Add-on code 29826.
The surgeon performed a decompression only with no acromioplasty. Would this be only coded as a debridement (29822/29823) depending on the op report below. I'm really not finding any information that is definitive or leaning in one direction more.
Patient is standard posterior arthroscopic portal portal established. The intra-articular findings include no significant articular cartilage changes in the humeral head or the glenoid. The biceps was intact. There was a significant tear of the labrum superiorly from about the 10 o'clock position around to the 2 o'clock position. There was a partial rotator cuff tear. A spinal needle was used to create an anterior working portal. Through this anterior working portal debridement of the superior labral tear was done. This did not require labral repair. A limited synovectomy and debridement of the partial rotator cuff tear was also done. The scope was placed both anteriorly and posteriorly in the shoulder and we worked both anteriorly and posteriorly in the shoulder. No significant other abnormalities findings were noted.
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The scope was then placed from the posterior portal into the subacromial space and a lateral working portal was established. The seem to be somewhat of a tight lateral space. A subacromial bursectomy was performed and then the bur was used to perform a bony decompression of the subacromial space. This decompressed the subacromial space nicely.
The surgeon performed a decompression only with no acromioplasty. Would this be only coded as a debridement (29822/29823) depending on the op report below. I'm really not finding any information that is definitive or leaning in one direction more.
Patient is standard posterior arthroscopic portal portal established. The intra-articular findings include no significant articular cartilage changes in the humeral head or the glenoid. The biceps was intact. There was a significant tear of the labrum superiorly from about the 10 o'clock position around to the 2 o'clock position. There was a partial rotator cuff tear. A spinal needle was used to create an anterior working portal. Through this anterior working portal debridement of the superior labral tear was done. This did not require labral repair. A limited synovectomy and debridement of the partial rotator cuff tear was also done. The scope was placed both anteriorly and posteriorly in the shoulder and we worked both anteriorly and posteriorly in the shoulder. No significant other abnormalities findings were noted.
*
The scope was then placed from the posterior portal into the subacromial space and a lateral working portal was established. The seem to be somewhat of a tight lateral space. A subacromial bursectomy was performed and then the bur was used to perform a bony decompression of the subacromial space. This decompressed the subacromial space nicely.