talitha82
Guest
I just began coding for a Doctor who states that he can bill a 29827 with a 22 modifier appended when he repairs a subscapularis tear. I am not sure I can code that, and am looking for some kind of documentation on whether or not this is allowed, as he would prefer to see it documented. Here is an example:
OPERATIVE REPORT
PREOPERATIVE DIAGNOSES: Impingement syndrome, rotator cuff tear, right shoulder.
POSTOPERATIVE DIAGNOSES: Impingement syndrome, rotator cuff tear, subscapularis tear, right shoulder.
PROCEDURE: Right shoulder arthroscopy, subacromial decompression, acromioplasty (29826), and repair of rotator cuff (29827-22).
INDICATIONS: Please see my dictated history and physical. The patient has been cleared for surgery. Risks, benefits, and options again were discussed with the patient today. He was seen and examined. Review of systems is negative. The patient wishes to proceed and this is now scheduled at his convenience.
PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After induction of adequate general anesthesia, 1 g Ancef was given. The patient was carefully placed in a beach chair position with all pressure points padded. The right shoulder was prepped and draped in a sterile manner. PlexiPulse boots were used during the entirety of the case.
Diagnostic arthroscopy was performed of the right glenohumeral joint and findings were as follows:
1. Glenohumeral surfaces were normal.
2. Inferior recess and posterior bare area was normal.
3. Anterior capsuloligamentous complex was essentially normal.
4. Posterior capsuloligamentous complex was essentially normal.
5. The biceps tendon appeared normal. There was perhaps some scuffing, but this appeared benign with no synovitis or active signs of tearing or inflammation.
6. The subscapularis was abnormal with a tear of the superior 1 to 1.5 cm of this tendon and mild retraction.
7. There was a tear of the rotator cuff, which appeared to be medium sized and crescentic in nature.
Based on these findings, I placed a cannula through the rotator cuff tear and also a cannula anteriorly. I created a bleeding bony bed and then one arthroscopic 4 and 5 anchor was placed at the superior aspect of the footprint of the subscapularis. Three sutures were then passed and the subscapularis was repaired.
The arthroscope was then removed and placed into the subacromial space. There was a very thick bursa, which was debrided. This was a very low outlet type II acromion with a fairly thick CA ligament. The CA ligament was transected. The acromion was then coplaned back. The AC joint was not violated. All debris was removed.
I then assessed the rotator cuff tear. This was a medium-sized crescentic tear.
I created a bleeding bony bed.
Then, using arthroscopic suture passing and knot-tying techniques, the rotator cuff repair was performed. The posterior sutures were cut. The anterior sutures were crossed and placed into the greater tuberosity using a PopLok device.
The arthroscope was reinserted to ensure that the biceps was incarcerated. It appeared free.
At this point, all debris was removed. Portals were closed in standard fashion. Sterile dressing was applied. The patient was awakened, transported to the recovery room in stable condition. There were no complications.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSES: Impingement syndrome, rotator cuff tear, right shoulder.
POSTOPERATIVE DIAGNOSES: Impingement syndrome, rotator cuff tear, subscapularis tear, right shoulder.
PROCEDURE: Right shoulder arthroscopy, subacromial decompression, acromioplasty (29826), and repair of rotator cuff (29827-22).
INDICATIONS: Please see my dictated history and physical. The patient has been cleared for surgery. Risks, benefits, and options again were discussed with the patient today. He was seen and examined. Review of systems is negative. The patient wishes to proceed and this is now scheduled at his convenience.
PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After induction of adequate general anesthesia, 1 g Ancef was given. The patient was carefully placed in a beach chair position with all pressure points padded. The right shoulder was prepped and draped in a sterile manner. PlexiPulse boots were used during the entirety of the case.
Diagnostic arthroscopy was performed of the right glenohumeral joint and findings were as follows:
1. Glenohumeral surfaces were normal.
2. Inferior recess and posterior bare area was normal.
3. Anterior capsuloligamentous complex was essentially normal.
4. Posterior capsuloligamentous complex was essentially normal.
5. The biceps tendon appeared normal. There was perhaps some scuffing, but this appeared benign with no synovitis or active signs of tearing or inflammation.
6. The subscapularis was abnormal with a tear of the superior 1 to 1.5 cm of this tendon and mild retraction.
7. There was a tear of the rotator cuff, which appeared to be medium sized and crescentic in nature.
Based on these findings, I placed a cannula through the rotator cuff tear and also a cannula anteriorly. I created a bleeding bony bed and then one arthroscopic 4 and 5 anchor was placed at the superior aspect of the footprint of the subscapularis. Three sutures were then passed and the subscapularis was repaired.
The arthroscope was then removed and placed into the subacromial space. There was a very thick bursa, which was debrided. This was a very low outlet type II acromion with a fairly thick CA ligament. The CA ligament was transected. The acromion was then coplaned back. The AC joint was not violated. All debris was removed.
I then assessed the rotator cuff tear. This was a medium-sized crescentic tear.
I created a bleeding bony bed.
Then, using arthroscopic suture passing and knot-tying techniques, the rotator cuff repair was performed. The posterior sutures were cut. The anterior sutures were crossed and placed into the greater tuberosity using a PopLok device.
The arthroscope was reinserted to ensure that the biceps was incarcerated. It appeared free.
At this point, all debris was removed. Portals were closed in standard fashion. Sterile dressing was applied. The patient was awakened, transported to the recovery room in stable condition. There were no complications.
This is a great help!