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Orthopaedic Shoulder SX with Multiple Procedures - Codes Needed

Charlyn Posted Tue 01st of October, 2019 12:39:38 PM
My surgeon did a Shoulder SX consisting of the following procedures - PROCEDURES: 1. Right shoulder open repair of rotator cuff tear. 2. Open superior capsular reconstruction. 3. Arthroscopic placement of glenoid anchors equivalent that of a labral repair. 4. Open hemi-shoulder arthroplasty. 5. Arthroscopic extensive debridement. 6. Compaction bone grafting for the proximal humerus My surgeon put this statement in the Op Notes for Mod 22....There is very increased complexity associated with this case since this included multiple procedures such that of rotator cuff repair as well as superior capsular reconstruction as well as a hemi-shoulder arthroplasty as well as placement of glenoid anchors and drill holes throughout the humerus. Procedure took an excess of 4 hours. The patient had a very severe debilitating shoulder injury which failed to respond to not only conservative measures, but also rotator cuff repair previously. The following are the Post Op DX: POSTOPERATIVE DIAGNOSES: 1. Right shoulder irreparable rotator cuff tear of the supraspinatus and infraspinatus. 2. Glenohumeral joint osteoarthritis. 3. Complex labral tear. 4. Retained foreign material. 5. Adhesive capsulitis. DETAILS OF PROCEDURE: The patient was met in the preoperative holding area where his right upper extremity was identified and marked. He was then brought to the operating room where he was prepped and draped in a sterile fashion and placed in a beach-chair position. Perioperative antibiotics were administered as well as tranexamic acid. A skin incision was made first and we introduced the scope. In Picture #1, we were identifying the arthrosis within the glenohumeral joint. Picture #2 is release of the capsule, which was performed with an ablator as we had to free up the labrum and ultimately place three glenoid anchors that were similar to that of anchors for labral repair and these were placed arthroscopically. Additionally, rotator cuff as well as capsular and labral tissue and bursal tissue were debrided, all of which consisted of an extensive debridement. This was in addition to the capsule, which was released essentially circumferentially. Picture #5 is identifying the glenoid rim bleeding bone edge to facilitate incorporation of the cadaveric allograft. Further debridement of the labrum was performed in Picture #6. Picture #7 is identifying the glenoid from the 50-yardline view, in which we were also visualizing the extensive tear of the rotator cuff. We were placing multiple anchors as in Pictures #8, #9, #10, and #11 and Picture #12 being the post-anchor placement, which measured between 13 mm and 15 mm between the front, middle, and posterior anchor respectively. Measuring of these anchors sites were in Picture #13. Once that was completed, we then converted to the open portion of the case, in which we placed in a slightly less beach-chair position and more semi-Fowler position. A deltopectoral approach was made and achieved with meticulous dissection. This biceps tendon was ultimately tenodesed with the superior border of the pectoralis. The three sisters were cauterized and the subscapularis was peeled off its attachment site. We then proceeded to dislocate the humerus and then performed a freehand cut according to his anatomy which was roughly 30 to 35 degrees of retroversion and anatomic inclination. Once that was completed, we proceeded to make multiple drill holes for reconstruction of the superior capsule. Multiple limbs of suture were placed throughout for both the lesser tuberosity as well as the greater tuberosity. We then proceeded to insert the permanent component which was a size 9 Arthrex humeral stem with a 54 x 23 head. In addition, compaction bone grafting was performed to the proximal humerus, which we harvested from the resected humeral head. After the humeral component was inserted, we then proceeded to make measurements for the capsular allograft. This was then cut to size and then utilizing the FastPass, multiple limbs of suture were passed and the graft was secured to the glenoid via the three glenoid anchors and this was essentially equivalent to that of repairing the labrum. We then tied the graft to the greater tuberosity as well as the remaining rotator cuff tissue and this consisted of the superior capsular reconstruction as well as repairing of the portion of the rotator cuff. The subscapularis was then repaired back to its native footprint and then the rotator interval was closed. It should be noted that we did cut enough graft in order to account for the closure of the rotator interval. After that was completed, we then took the shoulder through range of motion and was noted to be exceptionally stable as prior to the repair as well as reconstruction, the head was noted to translate very loosely in his shoulder, which was his native baseline.
SuperCoder Answered Thu 03rd of October, 2019 01:23:47 AM

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information.

Charlyn Posted Fri 04th of October, 2019 16:24:01 PM
Please forget I asked for help with this AND Please CANCEL my subscription IMMEDIATELY!

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