Wiki Is this a 23455??

[l1ttle_0ne]

Hello! I'm fairly new to coding ortho, and have never done this procedure before it was scheduled as a 23455 and 23585 for the fracture. I can understand the fracture part of the procedure, but I'm struggling to see if the 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) code fit's this op note. Any help you can provide would be great!

PREOPERATIVE DIAGNOSIS: Right shoulder dislocation with anteroinferior glenoid fracture and recurrent subluxation.
POSTOPERATIVE DIAGNOSIS: Right shoulder dislocation with anteroinferior glenoid fracture and recurrent subluxation.

OPERATION: Right shoulder glenoid fracture open reduction and internal fixation with stabilization of anterior dislocation .

INDICATIONS: The patient fell, dislocating her right shoulder. It was reduced in the emergency room, but follow up x-rays show subluxation with a displaced glenoid fracture. MRI scanconfirms the unstable displaced glenoid fracture with an intact rotator cuff. Due to the recurrent instability, shewishes to proceed with surgery.
PROCEDURE IN DETAIL: The patient was anesthetized with uncomplicated general endotracheal anesthesia and right interscalene nerve block. She was positioned in the modified beach chair position where she wascarefully padded and stabilized. Examination of the right shoulder revealed it to be subluxed anteriorly. Couldeasily be reduced, though with external rotation and mild abduction, it subluxed again. SCDs were fit on both legs to be used intra- and postoperatively. She was given 1 g of IV vancomycin within 1 hour of incision, whichwill be discontinued postoperatively. The right shoulder and upper extremity were prepped and draped in theusual sterile manner.A partial deltopectoral incision was made and dissection carried to the deltopectoral interval where the cephalicvein was easily identified. Hemostasis was procured. Blunt dissection developed the deltopectoral intervaland a self-retaining retractor inserted. The clavipectoral fascia was incised lateral to the conjoined tendon.The musculocutaneous and axillary nerves were palpated and protected throughout the case. With theshoulder in the reduced position, inspection revealed the subscapularis tendon to be intact as was thesupraspinatus. The circumflex humeral vessels were cauterized and transected inferior to the subscapularis.The subscapularis tendon was now carefully released 1 cm from its lesser tuberosity insertion. The underlyingcapsule was meticulously dissected from the subscapularis, preserving it. A tag suture was placed in thesubscapularis, and it was retracted medially.The capsule was now released from its humeral insertion and retracted medially. This afforded excellentaccess to the glenohumeral joint. A Fukuda retractor was inserted, and inspection showed the displacedanteroinferior glenoid fracture. The fragment measured approximately 3 x 6 mm, and it was withoutappreciable comminution. There was scuffing of the central glenoid articular surface, but otherwise, theglenoid was intact. The humeral articular cartilage was intact as was the biceps tendon. The fracture site wascleared of hematoma and the fracture fragment carefully mobilized until it could be reduced anatomically. Agood reduction was noted with good restoration of the glenoid vault. Due to the size of the fragment, screwfixation was deemed appropriate. A guide pin was inserted in the superior portion of the fragment. A secondguide pin was placed anteroinferiorly. The guide pin stabilized the fracture nicely, again with good reduction.Due to the complete visualization of the glenoid, the articular surface was easily avoided. The first guide pinwas over drilled. A partially threaded 3.5 mm cannulated screw with washer was passed over the guide pinand tightened, compressing the fracture nicely. Testing showed good stability. A second screw was placedover the second pin, again with good compression. Inspection revealed the glenoid to be without penetration.Range of motion showed the fracture to be stable, and with external rotation, stability was markedly improved.The articular surface was smooth.The shoulder was copiously irrigated and the Fukuda retractor removed. The capsule was carefully repairedanatomically with 0 FiberWire using an interrupted figure-of-eight suture. Range of motion of the shouldershowed it to be very stable. External rotation to 20° showed the repair to be stable. Further external rotationwas not attempted. There was no anterior instability with manual testing and with rotation. The subscapulariswas repaired with interrupted figure-of-eight #2 Ethibond sutures. Again, examination showed the repair to bestable. Palpation revealed the axillary nerve to be intact. The wound was irrigated. The subscapularis,deltoid, pectoralis, and subcutaneous tissue were infiltrated with Marcaine with epinephrine. Thesubcutaneous tissue was closed by layer with 2-0 Vicryl and the skin closed with a ZipLine wound closuredevice. The wound was sterilely dressed and an ABD placed in the axilla. The arm was placed back in herimmobilizer. The patient was awakened and taken to the recovery room in stable condition, having toleratedthe procedure well. There were no complications, and blood loss was estimated at 10 mL. No pathology wassent.FINDINGS: As noted in the body of the report above.

 

[NRaizman]

A Bankart was NOT performed. Repairing the capsule you cut on the way in is always included. Had the surgeon actually described a reconstruction of the capsulolabral complex, he could have made a case. He did not.

The only appropriate code here is 23585.

 

[l1ttle_0ne]

A Bankart was NOT performed. Repairing the capsule you cut on the way in is always included. Had the surgeon actually described a reconstruction of the capsulolabral complex, he could have made a case. He did not.

The only appropriate code here is 23585.

THANK YOU SO MUCH!! I've been staring at this thinking it didn't really fit, but so unsure! Your a life saver!

 

[amyjph]

From a coder's perspective, it is not as common to see 23455 for acute dislocations like this slip and fall as you would for chronic dislocations. It is also less common than the arthroscopic Bankart (29806). Not saying it doesn't happen, it's just not seen as much in my experience.

Also for your future sanity and reference, be careful looking at what something was "scheduled as" or what the authorization was for. They could be adding possible codes just to cover "in case". Also, if a certified coder is not pre-coding the surgery order or the auth and it's just coming from a template or an office staff person, it may not be correct as to what was actually planned or performed. I would even go so far as to tell you not to even look at what was scheduled or on the auth. Only go by the documentation in the operative report. When you are new it can really be confusing and too suggestive where you are trying to piece together a puzzle and make the "scheduled as" fit what was documented.

For Bankart you would be looking for the words labrum, labral repair, capsulorrhaphy, etc.

As Dr. Raizman said, there is no Bankart in that op note. These are the references to the capsule and would be included, " The underlying capsule was meticulously dissected from the subscapularis, preserving it." "The capsule was now released from its humeral insertion and retracted medially. " "The capsule was carefully repaired anatomically with 0 FiberWire using an interrupted figure-of-eight suture. "

Since you are new, it is helpful to outline the op note and use a cross-out method or highlight which part goes with each code you are trying to report. If you were to go through and highlight all the sections in this report that go with the ORIF, you would see there is nothing else left.