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New
Looking for guidance on the proper coding for the procedure below. We tried applying the logic used now for total knee/hip revisions - but shoulder codes are limited. Considered 11044 and 11981? with a modifier 59 on the 11044?
Any feedback appreciated, thank you!
PREOPERATIVE DIAGNOSIS:
Left shoulder status post reverse shoulder arthroplasty with now superficial versus possible deep infection of the shoulder.
POSTOPERATIVE DIAGNOSIS: Left shoulder deep infection of his left shoulder arthroplasty.
NAME OF PROCEDURES: Left shoulder resection/revision, total shoulder arthroplasty with removal of humeral stem, tray and polyethylene glenosphere, base plate and screws placement. Placement of cement spacer utilizing a 6B long stem cement spacer, also placement of 2 g of vancomycin powder. Also, irrigation and debridement utilizing 4000 mL of saline.
The patient had obvious swelling around his mid proximal portion of the incision. Incision was made and cultures were immediately obtained of the superficial fluid. Incision was carried down after hemostasis was obtained into the subcutaneous tissues around the fascia overlying the deltopectoral interval. This was incised. We removed previous Ethibond sutures that were in place here and deep entrance revealed fluid in the deep tissue and this was sent for culture as well. There was obviously infectious fluid present there. The capsule around the glenohumeral joint and the reverse joint was incised and then partially excised. With further excision, it allowed for dislocation of the joint and then the tray was removed. There was tissue deep to the tray and this was sent off. The proximal humerus was then evaluated. It was not obviously loose. The glenosphere was then evaluated and removed without difficulty. There was a fibrous tissue deep to it and this was sent for culture. The base plate was then removed without much difficulty after the screws had been removed. Tissue deep to this was sent for culture as well. The humeral stem was then removed with some difficulty utilizing osteotome proximally. There was an area of thinning of the bone, which allowed approach for a bony window. Following the removal of this, we sent tissue deep to this for culture. After this, the patient was given Zinacef 1.5 g. This was given IV. Extensive debridement was performed throughout the entire joint. This included the humeral shaft, the capsule in the synovium around the humerus, and then the glenoid. Over 9000 mL of fluid was used for irrigation throughout this portion. There was a pedestal within the proximal humerus, which was removed. The humerus was prepared and was felt that a size 6 long-stem cement spacer would be adequate or would be good fixation with a 23 mm head. This was then created using the molds. Again, complete debridement was performed throughout this procedure and then the cement spacer was placed into the proximal humerus prior to placing this. After copious irrigation, we did place approximately 1 g of vancomycin powder. The vancomycin powder was then placed in the deep tissue as well after reduction. The shoulder was closed deep with the capsule over as well as deltopectoral in 1 layer with utilizing 0 PDS suture and then closure in the superficial skin was performed with the #1 PDS in a skin inverting stitch over a drain in the subcutaneous area. We did resect the tissue of the incision prior to full closure to make sure that none of the necrotic tissue was present.
Any feedback appreciated, thank you!
PREOPERATIVE DIAGNOSIS:
Left shoulder status post reverse shoulder arthroplasty with now superficial versus possible deep infection of the shoulder.
POSTOPERATIVE DIAGNOSIS: Left shoulder deep infection of his left shoulder arthroplasty.
NAME OF PROCEDURES: Left shoulder resection/revision, total shoulder arthroplasty with removal of humeral stem, tray and polyethylene glenosphere, base plate and screws placement. Placement of cement spacer utilizing a 6B long stem cement spacer, also placement of 2 g of vancomycin powder. Also, irrigation and debridement utilizing 4000 mL of saline.
The patient had obvious swelling around his mid proximal portion of the incision. Incision was made and cultures were immediately obtained of the superficial fluid. Incision was carried down after hemostasis was obtained into the subcutaneous tissues around the fascia overlying the deltopectoral interval. This was incised. We removed previous Ethibond sutures that were in place here and deep entrance revealed fluid in the deep tissue and this was sent for culture as well. There was obviously infectious fluid present there. The capsule around the glenohumeral joint and the reverse joint was incised and then partially excised. With further excision, it allowed for dislocation of the joint and then the tray was removed. There was tissue deep to the tray and this was sent off. The proximal humerus was then evaluated. It was not obviously loose. The glenosphere was then evaluated and removed without difficulty. There was a fibrous tissue deep to it and this was sent for culture. The base plate was then removed without much difficulty after the screws had been removed. Tissue deep to this was sent for culture as well. The humeral stem was then removed with some difficulty utilizing osteotome proximally. There was an area of thinning of the bone, which allowed approach for a bony window. Following the removal of this, we sent tissue deep to this for culture. After this, the patient was given Zinacef 1.5 g. This was given IV. Extensive debridement was performed throughout the entire joint. This included the humeral shaft, the capsule in the synovium around the humerus, and then the glenoid. Over 9000 mL of fluid was used for irrigation throughout this portion. There was a pedestal within the proximal humerus, which was removed. The humerus was prepared and was felt that a size 6 long-stem cement spacer would be adequate or would be good fixation with a 23 mm head. This was then created using the molds. Again, complete debridement was performed throughout this procedure and then the cement spacer was placed into the proximal humerus prior to placing this. After copious irrigation, we did place approximately 1 g of vancomycin powder. The vancomycin powder was then placed in the deep tissue as well after reduction. The shoulder was closed deep with the capsule over as well as deltopectoral in 1 layer with utilizing 0 PDS suture and then closure in the superficial skin was performed with the #1 PDS in a skin inverting stitch over a drain in the subcutaneous area. We did resect the tissue of the incision prior to full closure to make sure that none of the necrotic tissue was present.