I had a question..So our provider did a right shoulder diagnostic arthroscopy and he ended up doing a subacromial decompression without acromioplasty, I understand we would use 29826 but that's only including acromioplasty.
does anyone know how we would code it? Or would we even code this?
Here's the report for more details:
Procedure:
1. Right shoulder diagnostic arthroscopy.
2. Right shoulder arthroscopic superior labrum anterior posterior tear repair.
3. Right shoulder arthroscopic debridement of rotator cuff tear.
4. Right shoulder arthroscopic subacromial decompression without acromioplasty.
Description of Procedure:
The patient was identified in the preoperative holding area and his right shoulder was marked with indelible ink by me after confirming that it was indeed the right shoulder that was to be operated on. At that point, a right interscalene block was performed by the anesthesia team. The patient was taken back to the operating room and placed in the supine position on the operating room table. Anesthesia team then administered general anesthesia. An examination under anesthesia of the right shoulder was performed. He had full range of motion. He then had gross instability anteriorly or posteriorly. At that point, the patient was turned into the left lateral decubitus position. A down peroneal nerve and lateral malleolus was well padded. The right upper extremity was then prepped and draped in usual sterile fashion. A time-out was taken identifying the patient with the procedure being a right shoulder arthroscopy with labral repair. All in the room verbally agreed. It was confirmed that Ancef was given for prophylactic purposes. The right upper extremity was placed in 10 pounds of balanced suspension. Following the time out and confirmation of administration of antibiotics, a posterior portal was created with #11 blade. The arthroscope was inserted into the glenohumeral joint atraumatically. A diagnostic arthroscopy was performed with the above findings noted. At that point using spinal needle localization, an anterior portal was created with #11 blade. A 7.0 mm cannula was then placed through the rotator interval. The glenoid was debrided on the superior aspect. An arthroscopic burr was then used to create a bleeding bone surface on the superior medial aspect of the glenoid. It should be noted that a sublabral foramen was noted anteriorly. I do not believe that this was pathologic. He did have displacement of the labral posterior to the biceps. There is some chondromalacia noted as well as labral foramen in addition to the labral displacement. At that point using a percutaneous technique, a 90-degree suture lasso was passed trans tenderness medial to the rotator cuff cable. This was then passed through the labrum just posterior to the biceps tendon. An Arthrex LabralTape suture was then shuttled through the chondral labral junction of the labrum. The sutures were then retrieved through the anterior portal. At that point, a 5 mm cannula was placed trans tenderness medial to the rotator cuff cable. The glenoid was then drilled just posterior to the biceps. The LabralTape was then retrieved through 5.0 mm cannula. At that point, the 2.9 mm PushLock was prepared. The LabralTape was threaded through the eyelet. At that pint, the PushLock was then malleted into position in the glenoid. This was performed after proper tensioning. Following the placement of the PushLock, the labrum was probed. It was found to be stable. At that point using an arthroscopic shaver, the undersurface of the rotator cuff was debrided. This was articular sided tear of the supraspinatus that was less than 20%. Following debridement of the rotator cuff tear, the arthroscope was removed and placed in the subacromial space. Significant amount of subacromial bursitis was also noted. I did perform a subacromial bursectomy. I did not take down the coracoacromial ligament or perform an acromioplasty. At this point, I copiously irrigated the shoulder. The portal sites were closed with 4-0 Nylon in simple fashion. Xeroform 4x4s ABDs were then placed. The patient was placed in a sling. He was placed in a supine position and awakened from anesthesia. He was then transferred to the recovery room in stable condition. There are no complications during or immediately following this procedure. The procedure was discussed with the patient as well as the patient?s family following the procedure.
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Does anyone know how to code the subacromial decompression? Please help
Thank you
does anyone know how we would code it? Or would we even code this?
Here's the report for more details:
Procedure:
1. Right shoulder diagnostic arthroscopy.
2. Right shoulder arthroscopic superior labrum anterior posterior tear repair.
3. Right shoulder arthroscopic debridement of rotator cuff tear.
4. Right shoulder arthroscopic subacromial decompression without acromioplasty.
Description of Procedure:
The patient was identified in the preoperative holding area and his right shoulder was marked with indelible ink by me after confirming that it was indeed the right shoulder that was to be operated on. At that point, a right interscalene block was performed by the anesthesia team. The patient was taken back to the operating room and placed in the supine position on the operating room table. Anesthesia team then administered general anesthesia. An examination under anesthesia of the right shoulder was performed. He had full range of motion. He then had gross instability anteriorly or posteriorly. At that point, the patient was turned into the left lateral decubitus position. A down peroneal nerve and lateral malleolus was well padded. The right upper extremity was then prepped and draped in usual sterile fashion. A time-out was taken identifying the patient with the procedure being a right shoulder arthroscopy with labral repair. All in the room verbally agreed. It was confirmed that Ancef was given for prophylactic purposes. The right upper extremity was placed in 10 pounds of balanced suspension. Following the time out and confirmation of administration of antibiotics, a posterior portal was created with #11 blade. The arthroscope was inserted into the glenohumeral joint atraumatically. A diagnostic arthroscopy was performed with the above findings noted. At that point using spinal needle localization, an anterior portal was created with #11 blade. A 7.0 mm cannula was then placed through the rotator interval. The glenoid was debrided on the superior aspect. An arthroscopic burr was then used to create a bleeding bone surface on the superior medial aspect of the glenoid. It should be noted that a sublabral foramen was noted anteriorly. I do not believe that this was pathologic. He did have displacement of the labral posterior to the biceps. There is some chondromalacia noted as well as labral foramen in addition to the labral displacement. At that point using a percutaneous technique, a 90-degree suture lasso was passed trans tenderness medial to the rotator cuff cable. This was then passed through the labrum just posterior to the biceps tendon. An Arthrex LabralTape suture was then shuttled through the chondral labral junction of the labrum. The sutures were then retrieved through the anterior portal. At that point, a 5 mm cannula was placed trans tenderness medial to the rotator cuff cable. The glenoid was then drilled just posterior to the biceps. The LabralTape was then retrieved through 5.0 mm cannula. At that point, the 2.9 mm PushLock was prepared. The LabralTape was threaded through the eyelet. At that pint, the PushLock was then malleted into position in the glenoid. This was performed after proper tensioning. Following the placement of the PushLock, the labrum was probed. It was found to be stable. At that point using an arthroscopic shaver, the undersurface of the rotator cuff was debrided. This was articular sided tear of the supraspinatus that was less than 20%. Following debridement of the rotator cuff tear, the arthroscope was removed and placed in the subacromial space. Significant amount of subacromial bursitis was also noted. I did perform a subacromial bursectomy. I did not take down the coracoacromial ligament or perform an acromioplasty. At this point, I copiously irrigated the shoulder. The portal sites were closed with 4-0 Nylon in simple fashion. Xeroform 4x4s ABDs were then placed. The patient was placed in a sling. He was placed in a supine position and awakened from anesthesia. He was then transferred to the recovery room in stable condition. There are no complications during or immediately following this procedure. The procedure was discussed with the patient as well as the patient?s family following the procedure.
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Does anyone know how to code the subacromial decompression? Please help
Thank you