Hi, I hope someone can help with this surgery. I am very new to ortho coding after coding ENT for 20+ years! The procedure listed is "Left shoulder arthroscopy and open anterior capsular tightening". Here is the body of the report.
The proposed arthroscopy portals were infiltrated with Sensorcaine as was the anterior shoulder in the area of the incision. The shoulder was grossly unstable. It spontaneously dislocated anteriorly and was easily reduced. The scope was placed in the posterior portal. The capsule was quite hyperemic. There was no evidence of a tear of the supraspinatus or the subscapularis tendon. The inferior labrum appeared to be intact. There did not appear to be an anterior inferior labrum. The capsule was completely detached from the anterior inferior glenoid. The biceps tendon was hyperemic. I did not appreciate a specific SLAP tear, although there was some hyperemia at the insertion of the biceps into the superior labrum. There was a Hill-Sachs lesion seen. It did appear to compromise the articular surface of the humeral head. At this point, I opted to do an open anterior capsular shift and tightening. A 4 cm longitudinal incision was made anteriorly over the coracoid process. The deltopectoral interval was identified. The deltoid was elevated from the proximal lateral aspect of the humerus. The clavipectoral fascia was divided longitudinally in line with the conjoined tendon. The conjoined tendon was retracted medially. The arm was externally rotated. The subscapularis tendon was divided in line with the fibers of the tendon. An elevator was used to identify and elevate the subscapularis muscle from the anterior capsule. A Gelpi retractor was put into the split subscapularis tendon and muscle. The capsule was opened horizontally. Retractor was placed along the anterior edge of the glenoid. Three G2 suture anchors were placed in the anterior inferior edge of the glenoid. There was excellent purchase and there was no violation of the cartilage of the glenoid. The inferior half of the capsule was pulled medially and superiorly. The capsule was tightened with the suture anchors. The arm was displaced posteriorly and slightly internally rotated while it was tightened. The repair was quite solid. The superior capsule was then pulled down over the inferior capsule using the previous sutures. The arm was stable when tested after the repair. The wound was copiously irrigated. The subscapularis tendon was reapproximated with #1 Ethibond stitch. The skin edges were reapproximated with 0 and 2-0 Vicryl and a running 3-0 Monocryl filament. Steri-Strips and a sterile compressive dressing were applied and the patient was awakened from anesthesia, extubated, and taken to recovery with stable vitals breathing spontaneously.
Would I code the arthroscopy code 29806 with a 29999 for the Open procedure? He says he did not appreciate a SLAP tear, so didn't think 29807 was appropriate. Any help would be appreciated! Thank you!!
The proposed arthroscopy portals were infiltrated with Sensorcaine as was the anterior shoulder in the area of the incision. The shoulder was grossly unstable. It spontaneously dislocated anteriorly and was easily reduced. The scope was placed in the posterior portal. The capsule was quite hyperemic. There was no evidence of a tear of the supraspinatus or the subscapularis tendon. The inferior labrum appeared to be intact. There did not appear to be an anterior inferior labrum. The capsule was completely detached from the anterior inferior glenoid. The biceps tendon was hyperemic. I did not appreciate a specific SLAP tear, although there was some hyperemia at the insertion of the biceps into the superior labrum. There was a Hill-Sachs lesion seen. It did appear to compromise the articular surface of the humeral head. At this point, I opted to do an open anterior capsular shift and tightening. A 4 cm longitudinal incision was made anteriorly over the coracoid process. The deltopectoral interval was identified. The deltoid was elevated from the proximal lateral aspect of the humerus. The clavipectoral fascia was divided longitudinally in line with the conjoined tendon. The conjoined tendon was retracted medially. The arm was externally rotated. The subscapularis tendon was divided in line with the fibers of the tendon. An elevator was used to identify and elevate the subscapularis muscle from the anterior capsule. A Gelpi retractor was put into the split subscapularis tendon and muscle. The capsule was opened horizontally. Retractor was placed along the anterior edge of the glenoid. Three G2 suture anchors were placed in the anterior inferior edge of the glenoid. There was excellent purchase and there was no violation of the cartilage of the glenoid. The inferior half of the capsule was pulled medially and superiorly. The capsule was tightened with the suture anchors. The arm was displaced posteriorly and slightly internally rotated while it was tightened. The repair was quite solid. The superior capsule was then pulled down over the inferior capsule using the previous sutures. The arm was stable when tested after the repair. The wound was copiously irrigated. The subscapularis tendon was reapproximated with #1 Ethibond stitch. The skin edges were reapproximated with 0 and 2-0 Vicryl and a running 3-0 Monocryl filament. Steri-Strips and a sterile compressive dressing were applied and the patient was awakened from anesthesia, extubated, and taken to recovery with stable vitals breathing spontaneously.
Would I code the arthroscopy code 29806 with a 29999 for the Open procedure? He says he did not appreciate a SLAP tear, so didn't think 29807 was appropriate. Any help would be appreciated! Thank you!!
Hills-Sach lesion dx is S42.20-