Billingandcoding2
Networker
I am not well versed in these types of procedures, our surgeons usually provide their own coding. They are not sure about the coding in this instance, and I'd like to get some help.
From a previous course I have noted "Was the poly liner not causing problems - was it removed for I&D due to infection? Might want to look at the arthrotomy codes instead". There is also guidance to report revision with modifier 52.
My thoughts:
Either 23040 or 23474-52
and 23031 for the cyst wall debridement.
Preoperative Diagnosis:
Persistent draining wound s/p R rTSA. Patient has been taking oral doxycycline since completion of surgery on 9/27.
Postoperative Diagnosis:
Same
Procedure:
R rTSA wash out, I&D, culture
Poly exchange
Subscapularis repair
EBL: 100 cc
Implants:
Procedure:
Patient was identified as, medical record number, in the preop holding area. Consent was reviewed with patient. Risks, benefits, and alternatives were discussed. All questions were answered. Surgical site was marked. Patient was taken back to the OR and transferred onto the operative table.
General anesthesia was administered. SCDs were placed on both legs. The patient was carefully positioned in the beach-chair position, padding all prominences. The operative extremity was prepped and draped in the usual sterile fashion. The patient was given pre-operative antibiotics. Verification of surgical site, patient identification, and surgical procedure planned was then confirmed by the circulating nurse and anesthetic team.
We used the previous deltopectoral incision and interval. About 300 cc of serosanguinous fluid poured out of the incision. No frank purulent material observed, but extensive discolored fibrinous material most consistent with a developing large seroma wall was observed. Blunt finger dissection was used to explore the deltopec interval and a deltoid retractor was used once we have the interval developed. I saw prosthesis and well repaired subscapularis. No frank pus was encountered but fibrinous tissue surrounding the prosthesis. As some shoulder infection can be indolent, decision was made to take down the subscap repair, dislocate the shoulder, do the poly-exchange, so we can wash out the posterior shoulder as well. I carefully removed the fiberwire suture from the previous subscap repair without damaging the tendon. Then gently dislocated the shoulder atraumatically. It was found to be very stable. Then we removed the poly with an osteotome; took deep fibrinous tissue in the joint for culture, then washed the joint copiously with bactisure, followed by 6L of normal saline. Once we were satisfied. We changed to clean set up and instruments. We placed new poly and reduced the shoulder without complication. Shoulder was taken through ROM, found to be smooth with no impingement or instability. I drilled two bone tunnels with a 2-0 drill bit in the LT and repaired the subscap back to its footprint with 2 number 2 fiberwire sutures. We placed vancomycin powder. Then I did extensive debridement to the large cyst wall to bleeding tissue to facilitate healing. I closed the deltopec interval. Then closed the cyst wall/dead space with 2-0 PDS sutures, followed by subcuticular 2-0 PDS, then 3-0 nylon in interrupted fashion. Patient had reactions to adhesive dressings in the past, so we used xeroform, gauze, ABDs, metapore tapes to prevent further irritation/reaction.
Patient tolerated procedure well, and was taken to postop recovery in stable condition.
Postop plan:
Follow intra-op culture
ID consult as inpatient
From a previous course I have noted "Was the poly liner not causing problems - was it removed for I&D due to infection? Might want to look at the arthrotomy codes instead". There is also guidance to report revision with modifier 52.
My thoughts:
Either 23040 or 23474-52
and 23031 for the cyst wall debridement.
Preoperative Diagnosis:
Persistent draining wound s/p R rTSA. Patient has been taking oral doxycycline since completion of surgery on 9/27.
Postoperative Diagnosis:
Same
Procedure:
R rTSA wash out, I&D, culture
Poly exchange
Subscapularis repair
EBL: 100 cc
Implants:
| Implant Name | Type | Inv. Item | Serial No. | Manufacturer | Lot No. | LRB | No. Used | Action |
| IMP SHLDR HUM SOCK PLS4 36MM - LOG4349021 | Generic | IMP SHLDR HUM SOCK PLS4 36MM | ENOVIS-CDRM_1195501 | 386P1354 | Right | 1 | Implanted |
Procedure:
Patient was identified as, medical record number, in the preop holding area. Consent was reviewed with patient. Risks, benefits, and alternatives were discussed. All questions were answered. Surgical site was marked. Patient was taken back to the OR and transferred onto the operative table.
General anesthesia was administered. SCDs were placed on both legs. The patient was carefully positioned in the beach-chair position, padding all prominences. The operative extremity was prepped and draped in the usual sterile fashion. The patient was given pre-operative antibiotics. Verification of surgical site, patient identification, and surgical procedure planned was then confirmed by the circulating nurse and anesthetic team.
We used the previous deltopectoral incision and interval. About 300 cc of serosanguinous fluid poured out of the incision. No frank purulent material observed, but extensive discolored fibrinous material most consistent with a developing large seroma wall was observed. Blunt finger dissection was used to explore the deltopec interval and a deltoid retractor was used once we have the interval developed. I saw prosthesis and well repaired subscapularis. No frank pus was encountered but fibrinous tissue surrounding the prosthesis. As some shoulder infection can be indolent, decision was made to take down the subscap repair, dislocate the shoulder, do the poly-exchange, so we can wash out the posterior shoulder as well. I carefully removed the fiberwire suture from the previous subscap repair without damaging the tendon. Then gently dislocated the shoulder atraumatically. It was found to be very stable. Then we removed the poly with an osteotome; took deep fibrinous tissue in the joint for culture, then washed the joint copiously with bactisure, followed by 6L of normal saline. Once we were satisfied. We changed to clean set up and instruments. We placed new poly and reduced the shoulder without complication. Shoulder was taken through ROM, found to be smooth with no impingement or instability. I drilled two bone tunnels with a 2-0 drill bit in the LT and repaired the subscap back to its footprint with 2 number 2 fiberwire sutures. We placed vancomycin powder. Then I did extensive debridement to the large cyst wall to bleeding tissue to facilitate healing. I closed the deltopec interval. Then closed the cyst wall/dead space with 2-0 PDS sutures, followed by subcuticular 2-0 PDS, then 3-0 nylon in interrupted fashion. Patient had reactions to adhesive dressings in the past, so we used xeroform, gauze, ABDs, metapore tapes to prevent further irritation/reaction.
Patient tolerated procedure well, and was taken to postop recovery in stable condition.
Postop plan:
Follow intra-op culture
ID consult as inpatient