Vol. 13 •Issue 2 • Page 8
Coding Corner
A Case Study Takes a Look at Musculoskeletal System Procedures
Case Study
Preoperative Diagnosis: Impingement syndrome and arthritis of the left shoulder
Postoperative Diagnosis: Impingement syndrome and arthritis of the left shoulder; glenohumeral and AC joint arthritis, severe
Procedure Performed: Arthroscopy of the left shoulder with extensive debridement, subacromial decompression and resection of the AC joint
Operative Technique: After the satisfactory introduction of a general anesthetic, the patient was placed in the opposite lateral decubitus position, and his left arm was suspended from Buck’s traction. The arthroscope was atraumatically introduced into the shoulder, and the interior contents were examined.
Interior contents of the shoulder showed marked glenohumeral erosion with a cobblestone appearance and short fibrillatory appearance to the humeral head and the glenoid. The head was affected somewhat worse than the glenoid. Degenerative testing was present at the labrum. Synovitis was present throughout. The rotator cuff was intact. Arthroscopic subacromial decompression ensued as follows, following extensive debridement in the joint and in the subacromial bursa.
Interior contents of the shoulder were remarkable for some fraying of the anterior synovium in the shoulder and an area around the labrum. This was extensively debrided. Attention was then turned to the subacromial area. The humeral head was perfect, as was the socket, and there were no Hill-Sachs or Bankart lesions.
The arthroscope was then placed posteriorly into the subacromial bursa, and a needle was used after outlining the clavicle and acromion on the skin. The needle was placed in a mid-lateral portion to ensure that it could reach the anterior and lateral aspects of the acromion. The cannula was then introduced, and the full radius resector 4.0 was used to excise all soft tissue off the lateral acromion, especially in the anterior acromion, thus defining these borders. This offered great assistance in overall orientation. The arthroscope was then switched to the mid-lateral portal, using switching sticks. The abrader was placed after decannulating it through the posterior portal. Using the posterior acromion as the cutting block, the anterior acromion was resulted, sweeping across to the level of the AC joint.
Fine debridement was done utilizing the full radius resector, after the bone was very soft. An excellent level surface was achieved. By using the full-radius blade, I was able to go in the mid-lateral portal and resect soft-tissue posterior to the mid-lateral portals. An excellent view of the cannula of the abrader and full radius was obtained. With this excellent view, it was determined with certainty that a straight acromioplasty was achieved using the cutting-block technique.
The patient was then awakened from this anesthetic and allowed to return to the recovery room. He tolerated the procedure well.
ICD-9-CM Code Assignments
Preoperative:
726.2 Affections of shoulder region, not elsewhere classified
Postoperative:
726.2 Affections of shoulder region, not elsewhere classified
715.91 Osteoarthritis, unspecified whether generalized or localized, shoulder region
CPT Code Assignments
The surgeon’s procedure description includes extensive joint debridement due to the marked glenohumeral erosion and synovitis. The subacromial bursa was also debrided. The surgeon then describes the decompression of the subacromial space and the acromioplasty.
To appropriately assign the codes for this procedure, find the terms Arthroscopy, Surgical and Shoulder (29806Ð29827) in the CPT manual index. The narrative descriptions will lead you to the correct CPT codes of 29826 and 29823.
Add the modifier LT (left side of the body) to both of the facility CPT codes to communicate that the procedure was performed on the left shoulder. On the second professional code, assign modifier 51 (multiple procedures).
Facility:
29826-LT Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release
29823-LT Arthroscopy, shoulder, surgical; debridement extensive
Professional:
29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release
29823-51 Arthroscopy, shoulder, surgical; debridement extensive
Kathleen A. Mundy is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.
