elenipete
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Anyone willing to help out a newbie?
Since coding orthopaedics is not my strong point, I thought I would do some practice. The following report is probably your standard shoulder surgery, but for beginners, it can be confusing. Whats bundled, what can you report.
Any help as to resources on orthopaedic coding would also be greatly appreciated.
PREOPERATIVE DIAGNOSIS: Impingement syndrome, left shoulder with acromioclavicular joint arthropathy and rotator cuff tear.
POSTOPERATIVE DIAGNOSIS:
1. Impingement syndrome, left shoulder with subacromial bursitis.
2. Acromioclavicular joint arthropathy, left shoulder.
3. Large full thickness rotator cuff tear, left shoulder.
OPERATIVE PROCEDURE:
1. Open subacromial decompression of the left shoulder with resection of the coracoacromial ligamnet.
2. Open Mumford procedure, left shoulder.
3. Open rotator cuf repair, left shoulder.
GROSS PATHOLOGY: This is a 47 year old female who injured her left shoulder in an accident and has been unable to get better. She has had physical therapy, she has had chiropractic care, she has had injections but has not improved. She is now brought to the operative suite for care.
Preoperatively, she has positive forward flexion impingement test, severe AC joint pain and a positive drop-arm test with weakness of her rotator cuff.
MRI of the shoulder shows impingement, AC joint arthropathy and a full thickness rotator cuff tear. Indeed at surgery, there was noted to be a silver dollar-sized rotator cuff tear which is full thickness. We were able to debride the edges and repair it primarily to the greater tuberosity.
She also had a low lying anterior acromion. She also had AC-joint arthropathy causing impingement on the supraspinatus. We resected the coracoacromial ligamnet and we removed the acromion and the distal clavicle.
DESCRIPTION OF OPERATION: The patient was seen properatively, the left shoulder was marked. She was taken to the OR. IV antibiotiics were given. General anesthesia was administered. The patient was placed in the bench chair position and oblique acromion. Skin, subcutaneous tissue, fat and fascia were retracted out of harms way. The deltoid was split in line with its fibers. We did place self-retaining retractor in place. I used the electrocautery to remove soft tissue from the undersurface of the acromion aand the distal clavicle. I used an ostcotome to remove half of the acromion and the distal 5mm of the clavicle. Once this was done, I used a rasp to smooth the undersurface of the bones and I did remove the coracoacromial ligament with the electrocautery. Once this was done we turned our attention to the rotator cuff, I did a bursectomy and with some mild internal rotation we could see the entire rotator cuff tear, I used a double-action rongeur to remove the cortical bone off the greater tuberosity and got down to bleeding cancellous bone. I then passed #2 and #5 Ethibond and was able to reapproximate the rotator cuff to the bone and to its antomic insertion site. We sutured the rotator cuff with approximately 8 figure-of-eight sutures. Range of motion was tested, there was no impingement, there was no retraction, and there was no tension on the rotator cuff repair. The wound was irrigated. The deltoid was reapproximated and the skin was closed. Sterile dressings were applied. The patient was placed in a slingg. She was awakened and returned to the recovery suite.
She will be seen in the office in approximately 1 week. Specific written and verbal instructions were given to the patient.
Where does my confussion come in? well after reading several articles:
Can you code the Mumford procedure, if it was only 5mm? 29824- but it is open so would it be 23120?
Is the subacromonial decompression included? Or can you add modifier 59 and which is it- 29826 or open- 23130?
And the rotator cuff repair- no mention of acute or chronic- so going by the "large" and "half dollar size" is it chronic? 23412?
So any help to this case and resources to orthpaedic surgical coding would be greatly appreciated.
Have a great weekend everyone
Since coding orthopaedics is not my strong point, I thought I would do some practice. The following report is probably your standard shoulder surgery, but for beginners, it can be confusing. Whats bundled, what can you report.
Any help as to resources on orthopaedic coding would also be greatly appreciated.
PREOPERATIVE DIAGNOSIS: Impingement syndrome, left shoulder with acromioclavicular joint arthropathy and rotator cuff tear.
POSTOPERATIVE DIAGNOSIS:
1. Impingement syndrome, left shoulder with subacromial bursitis.
2. Acromioclavicular joint arthropathy, left shoulder.
3. Large full thickness rotator cuff tear, left shoulder.
OPERATIVE PROCEDURE:
1. Open subacromial decompression of the left shoulder with resection of the coracoacromial ligamnet.
2. Open Mumford procedure, left shoulder.
3. Open rotator cuf repair, left shoulder.
GROSS PATHOLOGY: This is a 47 year old female who injured her left shoulder in an accident and has been unable to get better. She has had physical therapy, she has had chiropractic care, she has had injections but has not improved. She is now brought to the operative suite for care.
Preoperatively, she has positive forward flexion impingement test, severe AC joint pain and a positive drop-arm test with weakness of her rotator cuff.
MRI of the shoulder shows impingement, AC joint arthropathy and a full thickness rotator cuff tear. Indeed at surgery, there was noted to be a silver dollar-sized rotator cuff tear which is full thickness. We were able to debride the edges and repair it primarily to the greater tuberosity.
She also had a low lying anterior acromion. She also had AC-joint arthropathy causing impingement on the supraspinatus. We resected the coracoacromial ligamnet and we removed the acromion and the distal clavicle.
DESCRIPTION OF OPERATION: The patient was seen properatively, the left shoulder was marked. She was taken to the OR. IV antibiotiics were given. General anesthesia was administered. The patient was placed in the bench chair position and oblique acromion. Skin, subcutaneous tissue, fat and fascia were retracted out of harms way. The deltoid was split in line with its fibers. We did place self-retaining retractor in place. I used the electrocautery to remove soft tissue from the undersurface of the acromion aand the distal clavicle. I used an ostcotome to remove half of the acromion and the distal 5mm of the clavicle. Once this was done, I used a rasp to smooth the undersurface of the bones and I did remove the coracoacromial ligament with the electrocautery. Once this was done we turned our attention to the rotator cuff, I did a bursectomy and with some mild internal rotation we could see the entire rotator cuff tear, I used a double-action rongeur to remove the cortical bone off the greater tuberosity and got down to bleeding cancellous bone. I then passed #2 and #5 Ethibond and was able to reapproximate the rotator cuff to the bone and to its antomic insertion site. We sutured the rotator cuff with approximately 8 figure-of-eight sutures. Range of motion was tested, there was no impingement, there was no retraction, and there was no tension on the rotator cuff repair. The wound was irrigated. The deltoid was reapproximated and the skin was closed. Sterile dressings were applied. The patient was placed in a slingg. She was awakened and returned to the recovery suite.
She will be seen in the office in approximately 1 week. Specific written and verbal instructions were given to the patient.
Where does my confussion come in? well after reading several articles:
Can you code the Mumford procedure, if it was only 5mm? 29824- but it is open so would it be 23120?
Is the subacromonial decompression included? Or can you add modifier 59 and which is it- 29826 or open- 23130?
And the rotator cuff repair- no mention of acute or chronic- so going by the "large" and "half dollar size" is it chronic? 23412?
So any help to this case and resources to orthpaedic surgical coding would be greatly appreciated.
Have a great weekend everyone
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