Wiki Shoulder surgery - I am just looking

[tschrader]

Hello!

I am just looking for clarification on whether this should be billed or not. The doctor states in his procedures done:
rotator cuff repair
subacromial decompression
biceps tenotomy

The doctor dictates everything perfect for the biceps tenotomy and the rotator cuff repair but when it comes to the subacromial decompression somethings are left out.

He states:
scope places subacromially?.undersurface of the acromion, the AC ligament were debrided and released?..acromioplasty was done.

No subracomial decompression is documented or even a limited bursectomy was done.

I feel since he does not state that the subracromial decompression was done. A 29826 should not be coded. The code clearly states "Arthroscopy, shoulder, surgical: decompression of subacromial space with partial acromioplasty, with or without coracoacromial ligament release.

But I am being told otherwise that it can be billed. But i feel if it is not documented it should not be billed. It is part of this code and it does not state with or without the subacromial decompression.

Any feedback would be great!!!

Thanks

 

[Orthocoderpgu]

I agree with you

We bill out these three surgeries all the time. The questions is, why was the SAD (29826) performed? If the patient is symptomatic, has impingment syndrome:then the SAD is medically necessary and is an actual treatment. But if the SAD is done mainly for visulisation, then it's not billable. There should be documentation in an office visit, usually during reviewing an MRI that the patient has impingment syndrome and needs to have this done. But if there is no previous documentation and the physician really does not document what he did and why, then medical necessity is not met. I hope this helps.

 

[nyyankees]

Hello!

I am just looking for clarification on whether this should be billed or not. The doctor states in his procedures done:
rotator cuff repair
subacromial decompression
biceps tenotomy

The doctor dictates everything perfect for the biceps tenotomy and the rotator cuff repair but when it comes to the subacromial decompression somethings are left out.

He states:
scope places subacromially?.undersurface of the acromion, the AC ligament were debrided and released?..acromioplasty was done.

No subracomial decompression is documented or even a limited bursectomy was done.

I feel since he does not state that the subracromial decompression was done. A 29826 should not be coded. The code clearly states "Arthroscopy, shoulder, surgical: decompression of subacromial space with partial acromioplasty, with or without coracoacromial ligament release.

But I am being told otherwise that it can be billed. But i feel if it is not documented it should not be billed. It is part of this code and it does not state with or without the subacromial decompression.

Any feedback would be great!!!

Thanks

I see that a SAD is done many times with a RCR. I would Q the doc and see why it was done. My guess is that there was an impingement.