SGIVENS
New
I am in need of help. I have a provider who want to bill 23020 with every shoulder arthroplasty procedure he does and feels it is supported no matter if it is bundled or not. They have also stated that since a modifier is allowed I should just add the 59 modifier to show supporting the service even if he is releasing scar tissue to open the capsule. This current note he is arguing since he has done more then just release the capsule so need others opinion if it is felt that the 23020 is supported. I have been asked to find something other than CCI that shows the services bundle, so I even showed them that AAOS code-x even has them as bundled, but because a modifier can be added they want to bill. Any and all thoughts are appreciated.
OPERATIONS PERFORMED: Right reverse total shoulder arthroplasty, CPT code 23470 as well as resected tissue off the humeral head and glenoid for increased external rotation due to stiffness, which was CPT code 23020.
An approximate 12 cm incision was marked over the anterior shoulder in line with the deltopectoral approach. A deltopectoral approach was then used to provide exposure to the anterior aspect of the glenohumeral joint. We made the incision and exposed the subcutaneous fat and found the cephalic vein running in the interval. After the initial incision was made, we exposed and incised and released the fascia. Once we located cephalic vein at the deltopectoral interval, we separated the deltoid and pectoralis major muscles and then retracted the cephalic vein laterally along with the deltoid and the pectoralis muscles. We then incised the clavipectoral fascia lateral to the conjoined tendon and inserted Kolbel retractors underneath the conjoined tendon and underneath the middle deltoid. We then released the biceps tendon from the bicipital groove and along the rotator interval down to its glenoid attachment. We opened the rotator interval along the line of the biceps to the superior margin of the subscapularis. At this point, we isolated, clamped, and ligated the anterior humeral circumflex vessels lying across the anterior-inferior third of the subscapularis tendon. We digitally located the axillary nerve and protected it along the inferior capsule. We then located the insertion of the subscap tendon along the lesser tuberosity and performed a subscapularis tenotomy. Once that was performed, we used blunt dissection to separate the capsule from the subscapularis inferiorly and medially. We then released the rest of the anterior capsule of the subscapularis down to the glenoid rim. We placed traction sutures into the subscapularis tendon to control and mobilize it from the anterior glenoid neck. We then placed a retractor underneath the upper part of the humeral head and at this point dislocated the humerus. The entire humeral head was now envisioned with all capsular tissues removed to provide excellent exposure. We then released the anterior, inferior, and posterior glenohumeral ligaments to properly and concentrically centralized the humeral head. We then started our freehand resection technique for the humeral head preparation and resection. We placed a 142-degree head cutting template along the anterior aspect of the arm parallel to the shaft of the humerus and resected it with an oscillating power saw. We then attached the T-handle to the starter awl and created a pilot hole in line with the long axis of the humerus and then prepared the humeral canal using a bony impaction technique using stem trial and trial bodies to impact the cancellous bone into the humerus. We then traditionally reamed up into a size 10 stem, which at that point was felt to be a good fit into the humeral canal. With the size 10 trial in place, we attached the humeral reamer guide body corresponding to the humeral body height chosen and carefully drilled in the humeral reamer guide cutting guide body and stem trial into the humerus keeping in line with the long axis of the humerus. Using a slotted mallet, we carefully drilled with the reverse body stem trial to the humerus, which was in line. At this point, a size 10 trial was deemed to be good fit and we placed a humeral head protector over the top of the stem. We then turned our attention into the glenoid and placed a retractor posterior to the glenoid along with a Bankart retractor anterior to the shoulder. We removed the labrum around the glenoid in order to further see the borders. We then marked out the anterior and posterior as well as the inferior and superior borders and placed a glenoid wire guide into the center of the glenoid at the convergence. We then drove the wire into the glenoid until adequate purchase was achieved. We then attached an extra-small glenoid reamer to the straight drill shaft and then reamed accordingly until the transcortical contact had been achieved and cartilage had been removed. With the guide pin set in place, we connected the central drill with power saw and drilled over the pin guide until there was full contact between drill and the bone. We then centered the baseplate boss drill guide over the glenoid post within the center hole. Using a rongeur, we removed the remaining bone within the superior and inferior holes, and the central screw holes were placed for the baseplate to sit. We then inserted our baseplate sitting flush and fully tightened the internal rod at the glenoid base to secure the baseplate. We then placed a central side of the double drill guide within the center baseplate using a 2.5 mm drill bit, we drilled the anterior cortex until the scapula had been perforated. The length of the screw was indicated by the drill bit, and we used a depth gauge to assess optimal screw length. We then chose an appropriate screw length for the central post and introduced it into the hole and fully tightened it. The superior, anterior, posterior, and inferior holes were then drilled in a similar manner taking care to place screws into most optimal bone stock and we obtained transcortical purchase. We then placed our peripheral screws and retightened the central screw as needed. We then placed our locking screw caps over the superior and inferior screws and then tightened the locking caps until they were fully seated with the baseplate. We then trialed our glenosphere, which was found to be 2 mm concentric glenosphere as noted above. We then trialed our liners afterwards and found that a 6 mm liner with a good fit. We then assembled our humeral implant in the back table and inserted the body stem implant into the prepared humerus using the reverse humeral body inserter and extractor. We then placed our final implant into place as well as our poly liner and made sure that the poly liner made a 90-degrees angle to the osteotomy. We then reduced the joint and performed a final assessment of joint stability and range of motion, which were found to be stable. Once the final implant was in place, we repaired the subscapularis tendon with sutures placed prior to implant.
OPERATIONS PERFORMED: Right reverse total shoulder arthroplasty, CPT code 23470 as well as resected tissue off the humeral head and glenoid for increased external rotation due to stiffness, which was CPT code 23020.
An approximate 12 cm incision was marked over the anterior shoulder in line with the deltopectoral approach. A deltopectoral approach was then used to provide exposure to the anterior aspect of the glenohumeral joint. We made the incision and exposed the subcutaneous fat and found the cephalic vein running in the interval. After the initial incision was made, we exposed and incised and released the fascia. Once we located cephalic vein at the deltopectoral interval, we separated the deltoid and pectoralis major muscles and then retracted the cephalic vein laterally along with the deltoid and the pectoralis muscles. We then incised the clavipectoral fascia lateral to the conjoined tendon and inserted Kolbel retractors underneath the conjoined tendon and underneath the middle deltoid. We then released the biceps tendon from the bicipital groove and along the rotator interval down to its glenoid attachment. We opened the rotator interval along the line of the biceps to the superior margin of the subscapularis. At this point, we isolated, clamped, and ligated the anterior humeral circumflex vessels lying across the anterior-inferior third of the subscapularis tendon. We digitally located the axillary nerve and protected it along the inferior capsule. We then located the insertion of the subscap tendon along the lesser tuberosity and performed a subscapularis tenotomy. Once that was performed, we used blunt dissection to separate the capsule from the subscapularis inferiorly and medially. We then released the rest of the anterior capsule of the subscapularis down to the glenoid rim. We placed traction sutures into the subscapularis tendon to control and mobilize it from the anterior glenoid neck. We then placed a retractor underneath the upper part of the humeral head and at this point dislocated the humerus. The entire humeral head was now envisioned with all capsular tissues removed to provide excellent exposure. We then released the anterior, inferior, and posterior glenohumeral ligaments to properly and concentrically centralized the humeral head. We then started our freehand resection technique for the humeral head preparation and resection. We placed a 142-degree head cutting template along the anterior aspect of the arm parallel to the shaft of the humerus and resected it with an oscillating power saw. We then attached the T-handle to the starter awl and created a pilot hole in line with the long axis of the humerus and then prepared the humeral canal using a bony impaction technique using stem trial and trial bodies to impact the cancellous bone into the humerus. We then traditionally reamed up into a size 10 stem, which at that point was felt to be a good fit into the humeral canal. With the size 10 trial in place, we attached the humeral reamer guide body corresponding to the humeral body height chosen and carefully drilled in the humeral reamer guide cutting guide body and stem trial into the humerus keeping in line with the long axis of the humerus. Using a slotted mallet, we carefully drilled with the reverse body stem trial to the humerus, which was in line. At this point, a size 10 trial was deemed to be good fit and we placed a humeral head protector over the top of the stem. We then turned our attention into the glenoid and placed a retractor posterior to the glenoid along with a Bankart retractor anterior to the shoulder. We removed the labrum around the glenoid in order to further see the borders. We then marked out the anterior and posterior as well as the inferior and superior borders and placed a glenoid wire guide into the center of the glenoid at the convergence. We then drove the wire into the glenoid until adequate purchase was achieved. We then attached an extra-small glenoid reamer to the straight drill shaft and then reamed accordingly until the transcortical contact had been achieved and cartilage had been removed. With the guide pin set in place, we connected the central drill with power saw and drilled over the pin guide until there was full contact between drill and the bone. We then centered the baseplate boss drill guide over the glenoid post within the center hole. Using a rongeur, we removed the remaining bone within the superior and inferior holes, and the central screw holes were placed for the baseplate to sit. We then inserted our baseplate sitting flush and fully tightened the internal rod at the glenoid base to secure the baseplate. We then placed a central side of the double drill guide within the center baseplate using a 2.5 mm drill bit, we drilled the anterior cortex until the scapula had been perforated. The length of the screw was indicated by the drill bit, and we used a depth gauge to assess optimal screw length. We then chose an appropriate screw length for the central post and introduced it into the hole and fully tightened it. The superior, anterior, posterior, and inferior holes were then drilled in a similar manner taking care to place screws into most optimal bone stock and we obtained transcortical purchase. We then placed our peripheral screws and retightened the central screw as needed. We then placed our locking screw caps over the superior and inferior screws and then tightened the locking caps until they were fully seated with the baseplate. We then trialed our glenosphere, which was found to be 2 mm concentric glenosphere as noted above. We then trialed our liners afterwards and found that a 6 mm liner with a good fit. We then assembled our humeral implant in the back table and inserted the body stem implant into the prepared humerus using the reverse humeral body inserter and extractor. We then placed our final implant into place as well as our poly liner and made sure that the poly liner made a 90-degrees angle to the osteotomy. We then reduced the joint and performed a final assessment of joint stability and range of motion, which were found to be stable. Once the final implant was in place, we repaired the subscapularis tendon with sutures placed prior to implant.