NEOSM507
Guest
Hello,
Provider performed a remplissage in addition to a limited debridement and capsulorraphy. He is looking to code it as 29822, 29999 and 23462 (capsulorraphy anterior any type with coracoid process transfer ). I'm wondering if the remplissage is reported separately from the capsulorraphy or perhaps report the 23462 with a modifier 22 to identify the remplissage. Any advice would be great and appreciated. Thank you!!
Diagnostic arthroscopy was performed through standard posterior
and anterior interval portals. The glenohumeral surface showed some chondral damage
in the anterior inferior quadrant of the remaining glenoid articular cartilage.
There was significant anterior inferior bone loss and medial displacement of the
capsulolabral structures. He had a very long and broad and somewhat deep Hill-Sachs
lesion. The articular surface of the humeral head was in good condition. The
rotator cuff superior and posterior was intact. Biceps tendon to the anchor
superiorly was intact. Posterior labrum appeared to be intact as well.
Subscapularis also intact. The camera was then switched to the anterior portal and
an additional anteroposterior lateral portal was created outside in. The Hill-Sachs
lesion bed was prepared with a shaver to bony surface. Two 4.75-mm Healicoil anchors
then were placed at the nadir of the Hill-Sachs lesion and one suture from each of
these anchors passed to the additional posterolateral portal through infraspinatus
tissue. Both sutures were horizontal mattress sutures. They were left in situ and
not tied until the end of the case. Arthroscopic instruments were then removed from
the joint. An approximately 6 cm longitudinal incision was made from the tip of the
coracoid distally into the axillary crease. The deltopectoral interval was
identified. The cephalic vein was not encountered. The conjoint tendon and tip of
coracoid was identified and the coracoacromial ligament was divided approximately 1
cm from the coracoid. The pectoralis minor was dissected off the medial border of
the coracoid process. Approximately 2.5 cm of coracoid was then osteotomized, first
with the oscillating saw bent to about 70 degrees and then a curved osteotome cutting
from medial to lateral. After this was divided, gentle dissection was carried out to
mobilize the coracoid and conjoint tendon taking care to identify and protect the
musculocutaneous nerve. The axillary nerve was also identified and protected. The
coracoid was then prepared. The inferior surface was flattened with a saw to
decorticate it and make a flat surface for transfer. Two drill holes were made 1 cm
apart using a 2.7-mm drill. The coracoid was then placed medially and the arm was
placed in external rotation. The subscapularis was split in line with its fibers
approximately between the upper two-thirds and lower one-third of the muscle. This
was spilt down to capsule after which a sponge was placed medially followed by a Link
retractor and then a thin Hohmann inferiorly between the subscapularis and capsule,
which exposed the capsule. A vertical capsulotomy was performed right at the rim of
the glenoid. A Fukuda retractor was then replaced to retract the humeral head. The
capsulolabral remnants in the anterior inferior quadrant were then sharply dissected.
There was some suture material that was encountered and removed. The anterior
inferior glenoid was decorticated. There was a small amount of bony Bankart remnant
that was excised during this process. Once that was sufficiently prepared, the 8-mm
guide which had been measured previously from the holes drilled in the coracoid was
used to place the inferior drill hole for the inferior screw. This measured to a
total of 34-mm. The 34-mm screw was then passed through the inferior hole on the
coracoid transfer and then placed into the inferior hole, and this was tightened
provisionally. The coracoid graft was then rotated such that it was flush with the
glenoid surface. The superior glenoid hole was then drilled through the coracoid
graft. This measured a size 32 and so a 32-mm screw partially threaded 4.0-mm solid
screw was placed in the superior hole. The inferior screw was 34-mm partially
threaded 4.0-mm solid screw. Both screws were then tightened to finger tight to
reduce the graft to the edge of the glenoid. There was some overhang laterally of
the coracoid transfer, which was dealt with by shaving it down with a bur so it was
flush with the glenoid surface. The wound was copiously irrigated at that point.
The retractors were removed, and the coracoacromial ligament stump was sutured to the
lateral capsule. One single figure-of-eight suture was placed laterally to close the
lateral aspect of the subscapularis. The deltopectoral interval was reapproximated
with 0 Vicryl suture. Skin was then closed with 2-0 Vicryl and 3-0 Monocryl for the
longer incision and 4-0 Monocryl for the portals. Prior to closing the
posterolateral portal, the sutures for the remplissage were then tied and then suture
cut. Sterile dressings were applied followed by a shoulder brace. The patient was
then awoken from anesthesia without complication and taken to recovery room in stable condition.
Provider performed a remplissage in addition to a limited debridement and capsulorraphy. He is looking to code it as 29822, 29999 and 23462 (capsulorraphy anterior any type with coracoid process transfer ). I'm wondering if the remplissage is reported separately from the capsulorraphy or perhaps report the 23462 with a modifier 22 to identify the remplissage. Any advice would be great and appreciated. Thank you!!
Diagnostic arthroscopy was performed through standard posterior
and anterior interval portals. The glenohumeral surface showed some chondral damage
in the anterior inferior quadrant of the remaining glenoid articular cartilage.
There was significant anterior inferior bone loss and medial displacement of the
capsulolabral structures. He had a very long and broad and somewhat deep Hill-Sachs
lesion. The articular surface of the humeral head was in good condition. The
rotator cuff superior and posterior was intact. Biceps tendon to the anchor
superiorly was intact. Posterior labrum appeared to be intact as well.
Subscapularis also intact. The camera was then switched to the anterior portal and
an additional anteroposterior lateral portal was created outside in. The Hill-Sachs
lesion bed was prepared with a shaver to bony surface. Two 4.75-mm Healicoil anchors
then were placed at the nadir of the Hill-Sachs lesion and one suture from each of
these anchors passed to the additional posterolateral portal through infraspinatus
tissue. Both sutures were horizontal mattress sutures. They were left in situ and
not tied until the end of the case. Arthroscopic instruments were then removed from
the joint. An approximately 6 cm longitudinal incision was made from the tip of the
coracoid distally into the axillary crease. The deltopectoral interval was
identified. The cephalic vein was not encountered. The conjoint tendon and tip of
coracoid was identified and the coracoacromial ligament was divided approximately 1
cm from the coracoid. The pectoralis minor was dissected off the medial border of
the coracoid process. Approximately 2.5 cm of coracoid was then osteotomized, first
with the oscillating saw bent to about 70 degrees and then a curved osteotome cutting
from medial to lateral. After this was divided, gentle dissection was carried out to
mobilize the coracoid and conjoint tendon taking care to identify and protect the
musculocutaneous nerve. The axillary nerve was also identified and protected. The
coracoid was then prepared. The inferior surface was flattened with a saw to
decorticate it and make a flat surface for transfer. Two drill holes were made 1 cm
apart using a 2.7-mm drill. The coracoid was then placed medially and the arm was
placed in external rotation. The subscapularis was split in line with its fibers
approximately between the upper two-thirds and lower one-third of the muscle. This
was spilt down to capsule after which a sponge was placed medially followed by a Link
retractor and then a thin Hohmann inferiorly between the subscapularis and capsule,
which exposed the capsule. A vertical capsulotomy was performed right at the rim of
the glenoid. A Fukuda retractor was then replaced to retract the humeral head. The
capsulolabral remnants in the anterior inferior quadrant were then sharply dissected.
There was some suture material that was encountered and removed. The anterior
inferior glenoid was decorticated. There was a small amount of bony Bankart remnant
that was excised during this process. Once that was sufficiently prepared, the 8-mm
guide which had been measured previously from the holes drilled in the coracoid was
used to place the inferior drill hole for the inferior screw. This measured to a
total of 34-mm. The 34-mm screw was then passed through the inferior hole on the
coracoid transfer and then placed into the inferior hole, and this was tightened
provisionally. The coracoid graft was then rotated such that it was flush with the
glenoid surface. The superior glenoid hole was then drilled through the coracoid
graft. This measured a size 32 and so a 32-mm screw partially threaded 4.0-mm solid
screw was placed in the superior hole. The inferior screw was 34-mm partially
threaded 4.0-mm solid screw. Both screws were then tightened to finger tight to
reduce the graft to the edge of the glenoid. There was some overhang laterally of
the coracoid transfer, which was dealt with by shaving it down with a bur so it was
flush with the glenoid surface. The wound was copiously irrigated at that point.
The retractors were removed, and the coracoacromial ligament stump was sutured to the
lateral capsule. One single figure-of-eight suture was placed laterally to close the
lateral aspect of the subscapularis. The deltopectoral interval was reapproximated
with 0 Vicryl suture. Skin was then closed with 2-0 Vicryl and 3-0 Monocryl for the
longer incision and 4-0 Monocryl for the portals. Prior to closing the
posterolateral portal, the sutures for the remplissage were then tied and then suture
cut. Sterile dressings were applied followed by a shoulder brace. The patient was
then awoken from anesthesia without complication and taken to recovery room in stable condition.