Desperate Denise
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Fellow coders:
My boss in one week performed three surgical procedures and coded all three as 29826 and 29823. In each scenario - two of which are noted below. The third surgery involved a partial rotator cuff tear that he coded 29823. So there are three cases all with one diagnosis of impingement syndrome and procedure SAD 29826. The first op note the patient had glenohumeral arthritis, the second a labral tear and once again the third a rotator cuff tear. The CSI edits indicate that 29823 is bundled with 29826.
Any help will be GREATLY appreciated. Thank you!!!
FIRST OP-NOTE
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder pain.
2. Left shoulder glenohumeral joint arthritis.
3. Left shoulder impingement.
OPERATION PERFORMED:
1. Left shoulder arthroscopy.
2. Left shoulder glenohumeral joint debridement.
3. Left shoulder subacromial decompression.
The patient was brought into the preoperative area. Site and side were identified. There was no interscalene block administered. The patient was brought into the operating room and placed supine on the operating room table. Bony prominences were padded appropriately. General endotracheal intubation was performed. She was then placed in the beach-chair position. Examination of the left shoulder under anesthesia revealed full passive range of motion in all planes. The left upper extremity was prepped and draped in a sterile fashion. Bony landmarks of the shoulder including posterolateral, lateral and anterolateral aspects of the acromion were marked with a marking pen.
A mark was then made 2 fingerbreadths down and 2 fingerbreadths medial
from the posterolateral aspect of the acromion. An 18-gauge spinal needle
was inserted into the glenohumeral joint. The joint was distended with 60
mL of sterile saline. An 11-blade scalpel was used to incise the skin.
An arthroscope was introduced into the posterior aspect of the
glenohumeral joint and a diagnostic arthroscopy was begun. There was
evidence of grade 4 chondromalacial changes over the glenoid surface.
There were some grade 2-3 chondromalacial changes over the humeral head. These were in focal areas. No evidence of subscapularis muscle tear. The biceps tendon appeared to be in good condition. There was some tendinitis of the rotator cuff but no frank tearing. No evidence of loose bodies in the axillary pouch.
An anterior portal was established using an outside-in technique. An 18-
gauge spinal needle was inserted above the superior border of the
subscapularis. An 11-blade scalpel was used to incise the skin. A 7-mm
cannula from Arthrex was introduced into the glenohumeral joint. The
joint was debrided using an arthroscopic shaver. Once again the biceps
tendon was brought into the glenohumeral joint. There was no evidence of
biceps tendon pathology. The rotator cuff was intact.
Once all intra-articular work was complete, the arthroscope was removed
from the glenohumeral joint and introduced into the subacromial space from
a posterior approach. A lateral portal was established 3 fingerbreadths
down from the anterolateral aspect of the acromion. There was evidence of
bursitis and a bursectomy was performed. The undersurface of the acromion
was cleared of all soft tissue using the arthroscopic shaver as well as
the ArthroCare wand. The coracoacromial ligament was released. There was
evidence of a large subacromial spur. From a lateral portal using a 4-0
acromionizer bur a subacromial decompression was performed. Debridement
of the rotator cuff was performed from the subacromial space. The arm was
brought through both internal and external rotation. There was no
evidence of rotator cuff tearing.
Once all subacromial work was complete the arthroscopic instrumentation
was removed from the shoulder.
SECOND OP NOTE
POSTOPERATIVE DIAGNOSIS:
1. Right shoulder pain.
2. Right shoulder labral tear.
3. Right shoulder impingement with bursitis.
OPERATION PERFORMED:
1. Right shoulder arthroscopy.
2. Right shoulder glenohumeral joint debridement.
3. Right shoulder subacromial decompression.
Site and side were identified. The interscalene block was administered
and he was then brought into the operating room and placed supine on the
operating room table. Bony prominences were padded appropriately and
general endotracheal intubation was performed. He was then placed in the
beach-chair position. Examination of the right shoulder under anesthesia
revealed full passive range of motion in all planes. The right upper
extremity was prepped and draped in sterile fashion. Bony landmarks of
the shoulder including posterolateral, lateral, and anterolateral aspect
of the acromion were marked. The AC joint and the coracoid process were
marked as well. Then a mark was made 2 fingerbreadths down, 2 fingers
medial from the posterolateral aspect of the acromion. An 18-gauge spinal
needle was inserted into the glenohumeral joint. The joint was distended
with 60 mL of sterile saline. An 11-blade scalpel was used to incise the
skin. An arthroscope was introduced into the glenohumeral joint.
Diagnostic arthroscopy was begun. There was no evidence of chondromalacia of the glenoid or humeral surfaces. There was evidence of superior labral tear fraying. There was no evidence of subscapularis muscle tear. Biceps tendon was in good condition. Supraspinatus tendon was in good condition. Infraspinatus tendon was in good condition. There was no evidence of loose bodies within the axillary pouch. The anterior portal was established using an outside-in technique. An 18-guage spinal needle was inserted above the superior border of the subscapularis muscle. An 11- blade scalpel was used to incise the skin. A 7-mm cannula was introduced in the glenohumeral joint. Superior labrum was debrided. It was felt to be a type II SLAP lesion but this was chronic in nature. Peel off was negative. No evidence of fraying, biceps tendon instability. Biceps tendon was brought into the shoulder. There was no evidence of biceps tendinitis. Once all intra-articular work was completed, arthroscope was introduced into the subacromial space. A lateral portal was made 3
fingerbreadths down from the anterolateral aspect of the acromion. The 7-
mm cannula was introduced into the subacromial space. There was evidence of abundant bursitis. A complete bursectomy was performed using arthroscopic shaver as well as the ArthroCare wand. The undersurface of the acromion was cleared of all soft tissue. From the lateral portal using 4-0 acromionizer bur, a subacromial decompression was performed. Once the decompression was completed, all bursa was removed out through the rotator cuff. Arm was brought into internal and external rotations. There was no evidence of rotator cuff tear. Once all subacromial work was completed, arthroscope was removed from the shoulder.
My boss in one week performed three surgical procedures and coded all three as 29826 and 29823. In each scenario - two of which are noted below. The third surgery involved a partial rotator cuff tear that he coded 29823. So there are three cases all with one diagnosis of impingement syndrome and procedure SAD 29826. The first op note the patient had glenohumeral arthritis, the second a labral tear and once again the third a rotator cuff tear. The CSI edits indicate that 29823 is bundled with 29826.
Any help will be GREATLY appreciated. Thank you!!!
FIRST OP-NOTE
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder pain.
2. Left shoulder glenohumeral joint arthritis.
3. Left shoulder impingement.
OPERATION PERFORMED:
1. Left shoulder arthroscopy.
2. Left shoulder glenohumeral joint debridement.
3. Left shoulder subacromial decompression.
The patient was brought into the preoperative area. Site and side were identified. There was no interscalene block administered. The patient was brought into the operating room and placed supine on the operating room table. Bony prominences were padded appropriately. General endotracheal intubation was performed. She was then placed in the beach-chair position. Examination of the left shoulder under anesthesia revealed full passive range of motion in all planes. The left upper extremity was prepped and draped in a sterile fashion. Bony landmarks of the shoulder including posterolateral, lateral and anterolateral aspects of the acromion were marked with a marking pen.
A mark was then made 2 fingerbreadths down and 2 fingerbreadths medial
from the posterolateral aspect of the acromion. An 18-gauge spinal needle
was inserted into the glenohumeral joint. The joint was distended with 60
mL of sterile saline. An 11-blade scalpel was used to incise the skin.
An arthroscope was introduced into the posterior aspect of the
glenohumeral joint and a diagnostic arthroscopy was begun. There was
evidence of grade 4 chondromalacial changes over the glenoid surface.
There were some grade 2-3 chondromalacial changes over the humeral head. These were in focal areas. No evidence of subscapularis muscle tear. The biceps tendon appeared to be in good condition. There was some tendinitis of the rotator cuff but no frank tearing. No evidence of loose bodies in the axillary pouch.
An anterior portal was established using an outside-in technique. An 18-
gauge spinal needle was inserted above the superior border of the
subscapularis. An 11-blade scalpel was used to incise the skin. A 7-mm
cannula from Arthrex was introduced into the glenohumeral joint. The
joint was debrided using an arthroscopic shaver. Once again the biceps
tendon was brought into the glenohumeral joint. There was no evidence of
biceps tendon pathology. The rotator cuff was intact.
Once all intra-articular work was complete, the arthroscope was removed
from the glenohumeral joint and introduced into the subacromial space from
a posterior approach. A lateral portal was established 3 fingerbreadths
down from the anterolateral aspect of the acromion. There was evidence of
bursitis and a bursectomy was performed. The undersurface of the acromion
was cleared of all soft tissue using the arthroscopic shaver as well as
the ArthroCare wand. The coracoacromial ligament was released. There was
evidence of a large subacromial spur. From a lateral portal using a 4-0
acromionizer bur a subacromial decompression was performed. Debridement
of the rotator cuff was performed from the subacromial space. The arm was
brought through both internal and external rotation. There was no
evidence of rotator cuff tearing.
Once all subacromial work was complete the arthroscopic instrumentation
was removed from the shoulder.
SECOND OP NOTE
POSTOPERATIVE DIAGNOSIS:
1. Right shoulder pain.
2. Right shoulder labral tear.
3. Right shoulder impingement with bursitis.
OPERATION PERFORMED:
1. Right shoulder arthroscopy.
2. Right shoulder glenohumeral joint debridement.
3. Right shoulder subacromial decompression.
Site and side were identified. The interscalene block was administered
and he was then brought into the operating room and placed supine on the
operating room table. Bony prominences were padded appropriately and
general endotracheal intubation was performed. He was then placed in the
beach-chair position. Examination of the right shoulder under anesthesia
revealed full passive range of motion in all planes. The right upper
extremity was prepped and draped in sterile fashion. Bony landmarks of
the shoulder including posterolateral, lateral, and anterolateral aspect
of the acromion were marked. The AC joint and the coracoid process were
marked as well. Then a mark was made 2 fingerbreadths down, 2 fingers
medial from the posterolateral aspect of the acromion. An 18-gauge spinal
needle was inserted into the glenohumeral joint. The joint was distended
with 60 mL of sterile saline. An 11-blade scalpel was used to incise the
skin. An arthroscope was introduced into the glenohumeral joint.
Diagnostic arthroscopy was begun. There was no evidence of chondromalacia of the glenoid or humeral surfaces. There was evidence of superior labral tear fraying. There was no evidence of subscapularis muscle tear. Biceps tendon was in good condition. Supraspinatus tendon was in good condition. Infraspinatus tendon was in good condition. There was no evidence of loose bodies within the axillary pouch. The anterior portal was established using an outside-in technique. An 18-guage spinal needle was inserted above the superior border of the subscapularis muscle. An 11- blade scalpel was used to incise the skin. A 7-mm cannula was introduced in the glenohumeral joint. Superior labrum was debrided. It was felt to be a type II SLAP lesion but this was chronic in nature. Peel off was negative. No evidence of fraying, biceps tendon instability. Biceps tendon was brought into the shoulder. There was no evidence of biceps tendinitis. Once all intra-articular work was completed, arthroscope was introduced into the subacromial space. A lateral portal was made 3
fingerbreadths down from the anterolateral aspect of the acromion. The 7-
mm cannula was introduced into the subacromial space. There was evidence of abundant bursitis. A complete bursectomy was performed using arthroscopic shaver as well as the ArthroCare wand. The undersurface of the acromion was cleared of all soft tissue. From the lateral portal using 4-0 acromionizer bur, a subacromial decompression was performed. Once the decompression was completed, all bursa was removed out through the rotator cuff. Arm was brought into internal and external rotations. There was no evidence of rotator cuff tear. Once all subacromial work was completed, arthroscope was removed from the shoulder.