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Rotator Cuff

Carmel Posted Wed 10th of February, 2016 13:55:01 PM

here is the body of the note.

Dr. Office billed 23420 and 29824
I billed a 23412 and 29824.

Because the Acromioplasty was not performed as part of the open rotator cuff repair, nor does it say in the note that it was a 'reconstruction of the complete shoulder...'

I just want to make sure that I'm correct in my interpretation of 23420 vs 23412

PROCEDURE PERFORMED: Right shoulder arthroscopy, acromioplasty, coplaning distal clavicle, and
mini open rotator cuff repair.

PROCEDURE: The patient was brought to the operating room where she was placed in the supine position. After satisfactory anesthesia was induced she was prepped and draped in the sterile fashion. The right shoulder was approached through a posterior arthroscopy portal. Anterior and lateral portals were also utilized. The internal surfaces of the shoulder were evaluated. The labrum appeared to be intact anteriorly, superiorly, posteriorly, and inferiorly. The inferior glenohumeral recess was clear. The rotator cuff was identified as having a tear that appeared to be full thickness. We repositioned the scope into the subacromial space and using a suction ablater performed a bursectomy. When we had resected the bursa we were able to use a burr in a cutting block fashion and performed an acromioplasty. With the acromion converted from a type 2 to a 1 we also noted the distal clavicle was impinging into the rotator cuff and therefore we coplaned the inferior surface of the distal clavicle. Having done this we easily found the rotator cuff tear which was a full-thickness tear from the dorsal surface. We elected to make a small incision expanding the lateral portal and came down directly onto the rotator cuff. We were able to decorticate using a burr in the greater tuberosity. We used a single HealiCoil triple-loaded suture anchor and repaired the rotator cuff down to bone. With this completed we commenced closure. We irrigated and closed the deltoid with 0 Vicryl, the subcutaneous tissues with 2-0 Vicryl, and the skin with Prolene and nylon. We applied a sterile dressing, a shoulder immobilizing sling, and returned the patient to the recovery area in stable condition.

SuperCoder Answered Thu 11th of February, 2016 00:05:56 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.

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