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Shoulder Coding Strategies for ASC’s: How to obtain maximum reimbursement
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presents . . .
Shoulder Coding Strategies
for ASCs: How to obtain
maximum reimbursement
A 90-minute interactive audioconference
Wednesday, January 11, 2006
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ii
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
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Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
iii
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Dear colleague,
Thank you for participating in our “Shoulder Coding Strategies for
ASCs: How to obtain maximum reimbursement” audioconference with
Lolita Jones, RHIA, CCS, and Susan Vogelberger, CPC, CPC-H, moderated by Ilene MacDonald. We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to ask our experts your questions during the audioconference. If you
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iv
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
Contents
Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Presentation by Lolita Jones, RHIA, CCS, and Susan Vogelberger, CPC, CPC-H
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
v
Agenda
I. Anatomy of the Shoulder
A. Bones
B. Muscles/tendons
II. Terminology
III. Open Guidelines
A.. Acute vs. Chronic Rotator Cuff
i. Definition
ii. Documentation
iii. CPT
iv. ICD-9
B. Case Studies
i. RTC
ii. Mumford Procedure
iii. Subacromial decompression
iv. Bankart procedure
v. Capsulorrhaphy
vi. Manipulation
IV. Arthroscopic Guidelines
A. Modifier -59
B. ICD-9 V Codes
C. Miniarthrotomy
D. Case Studies
Live Q&A
vi
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
Speaker profiles
Lolita Jones, RHIA, CCS
Lolita Jones is the principal of Lolita M. Jones Consulting Services and vice president of educational programs at Medical Marketing Resources, Inc. She has over 15 years of experience in publishing, training, and
auditing for the hospital outpatient and freestanding ambulatory surgery center (ASC) markets.
Susan Vogelberger, CPC, CPC-H
Susan Vogelberger, founder and president of the Mahoning County Local Chapter of Professional Coders, is
currently employed by the Orthopaedic Surgery Center at Beeghly Medical Park in Boardman, OH, as the
business office coordinator/coder. Although her specialty is coding outpatient surgery, she is proficient in all
areas of coding and is also employed by Bryant & Stratton College as a PMCC instructor and presenter of
various workshops. She has been referenced and has authored articles regarding coding topics in several
publications. Vogelberger is an independent auditor and owner of Healthcare Consulting & Coding Education
based in Boardman. She serves on the editorial advisory board of the Hand Surgery Coding Alert and has
lectured during numerous coding seminars across the country.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
vii
Exhibit A
Presentation by Lolita Jones, RHIA, CCS, and Susan Vogelberger, CPC, CPC-H
EXHIBIT A
2
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
3
EXHIBIT A
4
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Terminology
The Bankart lesion is a specific injury to a part of the shoulder joint called
the labrum. The shoulder joint is a ball and socket joint, similar to the hip;
however, the socket of the shoulder joint is extremely shallow, and thus
inherently unstable.
To compensate for the shallow socket, the shoulder joint has a cuff of
cartilage called a labrum that forms a cup for the end of the arm bone
(humerus) to move within. This cuff of cartilage makes the shoulder joint
much more stable, yet allows for a very wide range of movements (in fact,
the range of movements your shoulder can make far exceeds any other
joint in the body).
When the labrum of the shoulder joint is torn, the stability of the shoulder
joint is compromised.
A specific type of labral tear is called a Bankart lesion. A Bankart lesion
happens when an individual sustains a shoulder dislocation. As the
shoulder pops out of joint, it often tears the labrum, especially in younger
patients. The tear is to part of the labrum called the inferior glenohumeral
ligament.
Terminology
Typical symptoms of a Bankart lesion include a catching, aching, and
susceptibility to dislocation; often patient will complain that they cannot
"trust" their shoulder. Diagnosis can be difficult as these injuries do not
always show up well on MRI scans. This is more of a clinical diagnosis with
the definitive diagnosis of a Bankart lesion made at the time of surgery.
Patients who sustain a Bankart injury are at much higher risk for dislocating
their shoulder again. Treatment of a Bankart lesion often depends on
whether or not a patient has recurrent episodes of shoulder instability.
When there is suspicion for a Bankart lesion, attempts at physical therapy to
strengthen the shoulder may help to reduce the risk of repeat dislocation. If
strengthening does not help the problem, shoulder arthroscopy can be
performed, and the injury can be definitively diagnosed and treated. A
Bankart repair is surgery to repair the torn ligament back to the shoulder
socket. The actual Bankart repair can either be performed through an
arthroscope or through an incision over the front of the shoulder.
Whether or not a Bankart repair is done arthroscopically or through an
incision (a so-called open Bankart repair) depends on several factors.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
5
EXHIBIT A
Terminology
Shoulder instability is a problem that occurs when the structures that
surround the glenohumeral (shoulder) joint do not work to maintain the ball
within its socket. If the joint is too loose, is may slide partially out of place, a
condition called shoulder subluxation. If the joint comes completely out of
place, this is called a shoulder dislocation. Patients with shoulder
instability often complain of an uncomfortable sensation that their shoulder
may be about to slide out of place--this is what physicians call apprehension.
If therapy fails, there are surgical options that can be considered.
Depending on the cause of the instability, the surgical treatments may be
quite different.
Terminology
If the cause of the shoulder instability is a loose shoulder joint capsule, then
a procedure to tighten the capsule of the shoulder may be considered. This
can be done with an arthroscope in a procedure called a thermal capsular
shrinkage. In this surgery, a heated probe shrinks the shoulder capsule to
tighten the tissue. The more standard method of this procedure is called an
open capsular shift. In this surgery, the shoulder joint is opened through a
larger incision, and the capsule is tightened with sutures. The advantage of
the open capsular shift is that the results are more predictable. The
advantage of the arthroscopic procedure is that the recovery is faster and
the incision is smaller. Sometimes a particular problem is better suited to
one procedure or the other, discuss this with your doctor.
If the problem is due to a tearing of the ligaments around the shoulder,
called the labrum, then a procedure called a Bankart repair can be
performed to fix this ligament. A Bankart repair can also be done either
through an incision or an arthroscope. Again, the results of the open
procedure are more predictable (more patients get better), but the
arthroscopic procedure does not leave as large an incision.
6
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Coding for Rotator Cuff Tears
The rotator cuff consists of four muscles; the superspinatus, infraspinatus,
subscapularis, and teres minor that fuse together to maintain stability of
the shoulder.
Arthroscopic: 29827 is for an acute or chronic injury.
Open: 23410 is for an acute injury with early repair.
23412 is for chronic tears, degenerative conditions usually in older patients
occurring over time.
23410 and 23412 describe rotator cuff repairs involving one or two tendons
or major muscles of the rotator cuff.
23420 describes a repair of a complete shoulder rotator cuff avulsion and
refers to the repair of all three major muscles/tendons of the shoulder cuff,
usually with extensive releases and mobilizations, tissue repositioning,
and/or use of fascial or synthetic grafting.
For mini-open rotator cuff repair, use 23412.
Acute vs. Chronic
Acute vs. chronic is up to interpretation as there is no
standardized definition to distinguish between the two. A
commonly used time frame is three months or less for
acute, and greater than three monthsfor chronic. Most
RTC repairs are for chronic conditions. A chronic tear
could have an acute episode but should still be coded as
chronic. Chronic vs. acute should be determined by the
physician and clearly documented in the patient’s record.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
7
EXHIBIT A
Bundling Issues
Procedures often performed with a RTC repair include
acromioplasty (29826, 23130), distal clavicle resection
(29824, 23120), debridement (29823, 29824), and
biceps tenodesis 29999, 23430). Remember to check
the Medicare Correct Coding Guide for bundling issues
and appropriate application of modifiers.
Example
RTCRepair
Repair
Exampleof
of Open
Open RTC
“………The
placed
abductedposition.
position. We
with
a 7-cm
Saber
type type
“………The
armarm
waswas
placed
in in
abducted
Weproceeded
proceeded
with
a 7-cm
Saber
incision.
Sharp
dissection
wascarried
carried down
down through
the
soft
tissue
untiluntil
the the
fascia
incision.
Sharp
dissection
was
through
the
soft
tissue
fascia
over the acromion was encountered. Medial and lateral skin flaps were elevated.
over The
the deltoid
acromion
anddetached
lateral skin
were elevated.
waswas
split encountered.
along its anteriorMedial
raphe and
fromflaps
the anterior
portion
The deltoid
was splitExposure
along itsincluded
anteriorthe
raphe
and detachedjoint
from
thedistal
anterior
of the acromion.
acromio-clavicular
. The
one portion
cm
of theofacromion.
Exposure
included
acromio-clavicular
joint . The distal
one cm
the clavicle was
excised.
We thenthe
proceeded
with a Neer acromioplasty.
At this
we were
to visualize
the superior
surface
of the
rotator
cuff tear
of thepoint
clavicle
wasable
excised.
We then
proceeded
with
a Neer
acromioplasty.
At this
which
corresponded
to the previous
arthroscopic
description.
pointconfiguration,
we were able
to visualize
the superior
surface
of the rotator
cuff tearThe
tendon
was
debrided
to
a
stable
viable
edge.
A
bone
trough
was
created
in
the
configuration, which corresponded to the previous arthroscopic description. The
greater
Wea first
proceeded
with repairing
thetrough
infratendinous
split ininthe
tendon
was tuberosity.
debrided to
stable
viable edge.
A bone
was created
the
supraspinatus.
This
proceeded
with a with
total of
four #2 Ethibond
sutures passed
greater
tuberosity.
We
first
proceeded
repairing
the
infratendinous
splitinina the
figure-of-eight fashion. The supraspinatus avulsion was then reattached to the
supraspinatus.
This proceeded
with
a total sutures.
of four #2
Ethibond
passed in a
greater tuberosity
utilizing two #2
Ethibond
These
suturessutures
were passed
figure-of-eight
Theasupraspinatus
avulsion
wassuture
then was
reattached
to the
through thefashion.
tendon using
modified Bunnell
stitch. The
passed through
greater
utilizing
#2a Ethibond
sutures.
These
were
the tuberosity
bone tunnels
and tiedtwo
over
bone bridge.
The repair
wassutures
reinforced
withpassed
a series
of 0 the
Vicryl
figue-of-eight
along
the tendinous
A watertight
closure through
was
through
tendon
using astitches
modified
Bunnell
stitch. edge.
The suture
was passed
achieved.
The
repair
was
stable
to
the
arm
in
the
abducted
position
and
with
range
the bone tunnels and tied over a bone bridge. The repair was reinforced with a series
of
motion.
The
wound
was
irrigated
with
copious
amounts
of
antibiotic
saline
of 0 Vicryl figue-of-eight stitches along the tendinous edge. A watertight closure was
throughout
procedure.
The deltoid
was reattached
to the acomion
achieved.
The the
repair
was stable
to the arm
in the abducted
positionusing
and four
with#2
range
Ethibond
sutures
in a Job irrigated
type stitch.
The
split in the
acromioclavicular
joint
was
of motion.
The
wound
with
copious
amounts
antibiotic
saline
approximated
with 0 was
Vicryl suture using
figure-of-eight
stitch. of
The
split in the
anterior
throughout
the
procedure.
The
deltoid
was
reattached
to
the
acomion
using
four
#2
raphe to the deltoid was re-approximated with 0 Vicryl suture using figure-of-eight
Ethibond
in a Jobwas
type
stitch.
split in the
acromioclavicular joint was
stitch.sutures
A pain catheter
placed
in aThe
subacromial
position………….”
approximated with 0 Vicryl suture using figure-of-eight stitch. The split in the anterior
raphe to the deltoid was re-approximated with 0 Vicryl suture using figure-of-eight
stitch. A pain catheter was placed in a subacromial position………….”
8
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Debridement
Debridement
In 2002 the AAOS came out with guidelines for limited vs. extensive
In 2002 the AAOS came out with guidelines for limited vs. extensive
debridement.
Debridement that addresses only the glenoid labrum or
debridement. Debridement that addresses only the glenoid labrum or
is performed
thefront
front
the shoulder
is reported
is performedin
in either
either the
or or
thethe
backback
of theofshoulder
is reported
using
29822.
thefront
front
and
back
are addressed,
use
code 29823.
using
29822. IfIf both
both the
and
back
are addressed,
use code
29823.
CPT
29822includes:
includes:
CPT
29822
Diagnostic shoulder
Diagnostic
shoulderarthroscopy
arthroscopy
Synovectomy
Synovectomy
Labral debridement
Labral
debridement
Removal
of osteophyte from humerus/glenoid
Removal
of osteophyte
from humerus/glenoid
Articular shaving
and/or chondroplasty
CPT 29823
includes:
Articular
shaving and/or chondroplasty
Diagnostic
shoulder arthroscopy
CPT 29823
includes:
Articular shaving/limited synovectomy
Diagnostic
shoulder arthroscopy
Synovectomy
Articular
shaving/limited
synovectomy
Biceps tendon and/or rotator
cuff debridement
Synovectomy
Labrum debridement
Removal
of osteophyte
humerous/glenoid
Biceps
tendon
and/or from
rotator
cuff debridement
Removaldebridement
of osteochondral and/or chondral bodies (attached)
Labrum
Abrasion arthroplasty
Removal
of osteophyte from humerous/glenoid
Removal of osteochondral and/or chondral bodies (attached)
Abrasion arthroplasty
SLAP
ofthe
theShoulder
Shoulder
SLAPLesion
Lesion of
(Superior
Labrum
Anterior-Posterior) is is
a term
used
to describe
a specific
type
SLAPSLAP
(Superior
Labrum
Anterior-Posterior)
a term
used
to describe
a specific
type
of injury
to the
shoulder
joint. The
The shoulder
a ball-and-socket
type of
jointof
and
is and is
of injury
to the
shoulder
joint.
shoulderis is
a ball-and-socket
type
joint
anatomically referred to as the gleno-humeral joint, describing the two bony
anatomically
assocket
the gleno-humeral
joint,adescribing
bony
structuresreferred
involved.toThe
is the glenoid cavity,
cup-shaped the
piecetwo
of bone
structures
involved.
The
socket
is scapula.
the glenoid
a glenoid
cup-shaped
ofby
bone
that juts
out from the
corner
of the
The cavity,
rim of the
cavity ispiece
formed
that juts
out from
theball
scapula.
The
of the
glenoid
cartilage
calledthe
thecorner
labrum. of
The
that fits into
therim
socket
is the
head ofcavity
the is formed by
humerus.
partThe
of the
labrum
the twoistendons
of the
cartilage
calledThe
thesuperior
labrum.
ball
that anchors
fits intoone
theofsocket
the head
of the
bicepsThe
muscle.
The other
is attached
the front
of the
to theof the
humerus.
superior
partbiceps
of thetendon
labrum
anchorsinone
of the
twochest
tendons
coracoid
process,
an
extension
of
the
shoulder
blade.
What
makes
SLAP
possible
is
bicepsthemuscle.
The other
tendon
is the
attached
front ofAs
the
way the upper
bicepsbiceps
tendon hooks
over
head ofin
thethe
humerus.
thechest
arm isto the
coracoid
process,
an
extension
of
the
shoulder
blade.
What
makes
SLAP
possible
is
forcefully bent inward at the shoulder, the humerus acts as a lever and tears the
the way
thetendon
upperand
biceps
over
the head
ofan
the
humerus. As the arm is
bicep
labrumtendon
cartilagehooks
from the
glenoid
cavity in
anterior-posterior
direction.
forcefully
bent inward at the shoulder, the humerus acts as a lever and tears the
bicep tendon and labrum cartilage from the glenoid cavity in an anterior-posterior
direction.
There are several ways to code SLAP lesions depending on the type of lesion and
the method of repair. Type I is repaired by debridement and is coded 29822.
Repairs of types II and IV are coded 29807 because an actual repair is performed.
ThereType
are III
several
ways
to code
SLAP
on29807.
the type
tears can
be either
debrided
or lesions
repaired depending
using 29822 or
Do of
notlesion
report and
29806 capsulorrhaphy
withI aisSLAP
repairby
unless
there is a capsular
defect in29822.
an area
the method
of repair. Type
repaired
debridement
and is coded
different
than II
theand
SLAP
Repairs
of types
IV lesion.
are coded 29807 because an actual repair is performed.
Type III tears can be either debrided or repaired using 29822 or 29807. Do not report
29806 capsulorrhaphy with a SLAP repair unless there is a capsular defect in an area
different than the SLAP lesion.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
9
EXHIBIT A
Types of SLAP Lesions
Type I
Degenerative fraying of the superior portion of the labrum, labrum
remains firmly attached to the glenoid rim
Type II
Separation of the superior portion of the glenoid labrum and the
tendon of the biceps brachii muscle from the glenoid rim
Type III
Bucket-handle tears of the superior portion of the labrum without
involvement of the brachii (long head) attachment
Type IV Bucket-handle tears of the superior portion of the labrum extending
into the biceps tendon
Type V
Anterior inferior Bankart lesion that extends upward to include a
separation of biceps tendon
Type VI Unstable radial of flap tears associated with separation of the biceps
anchor
Type VII Anterior extension of the SLAP lesion beneath the middle
glenohumeral ligament
Arthroscopic
CodingGuidelines
Guidelines
Arthroscopic Coding
Arthroscopic Shoulder
Shoulder Heat
A. A.Arthroscopic
HeatApplication
Application
Assignunlisted
unlisted arthroscopy
arthroscopy CPT
code
29999
to report
the use
heat
Assign
CPT
code
29999
to report
theofuse
oftoheat to
shrink the capsule in the shoulder performed through an arthroscope.
shrink
the
capsule
in
the
shoulder
performed
through
an
arthroscope.
(Source: CPT Assistant newsletter, August 1998, page 11.)
(Source: CPT Assistant newsletter, August 1998, page 11.)
B. Arthroscopic Shoulder Decompression of Subacromial Space with
Partial Acromioplasty
B. Arthroscopic
Shoulder Decompression of Subacromial Space with
Partial
Acromioplasty
The arthroscopic
procedure involves exposing the subacromial space,
bursectomy,
debridement,
detaching
theexposing
coracoacromial
ligament andspace,
The
arthroscopic
procedure
involves
the subacromial
removing thedebridement,
undersurface of
the acromion.
When subacromial
bursectomy,
detaching
the
coracoacromial
ligament and
decompression is performed, a flat undersurface of the acromion and
removing
the undersurface
of the acromion.
When
subacromial outlet
acromioclavicular
joint is produced,
which enlarges
the supraspinatus
decompression
is performed, a flat undersurface of the acromion and
and prevents impingement.
acromioclavicular joint is produced, which enlarges the supraspinatus outlet
and
prevents impingement.
Coding Tip: The partial acromioplasty, arch decompression, excision of
bursal tissue and release of the coracoacromial ligament would not be
reported
separately,
as these
are considered
to decompression,
be inclusive components
of of
Coding
Tip:
The partial
acromioplasty,
arch
excision
code tissue
29826. and
[Source:
Mayof2001
Assistant newsletter,
AMA]
bursal
release
the CPT
coracoacromial
ligament
would not be
reported separately, as these are considered to be inclusive components of
code 29826. [Source: May 2001 CPT Assistant newsletter, AMA]
10
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Arthroscopic Coding
Guidelines
Arthroscopic
Coding
Guidelines
C. Arthroscopic Rotator Cuff Repair
C. Arthroscopic
Rotator
Cuff Repair
Rotator cuff injuries
are strains
or tears of one or more rotator muscles or
tendons,
theinjuries
most common
site being
the supraspinatous
muscle.
Rotator
cuff
are strains
or tears
of one or more
rotatorAcute
muscles or
tears result
suchsite
as falls
on the
an outstretched
hand or
injuries Acute
tendons,
thefrom
mosttrauma,
common
being
supraspinatous
muscle.
fromresult
football
throwing,
baseball
pitching.
Racquetballhand
serving
tears
from
trauma,
such or
assoftball
falls on
an outstretched
ororinjuries
manipulation of a frozen shoulder. Chronic tears originate from over-use or
from
football
throwing,
baseball
or
softball
pitching.
Racquetball
serving or
constant stress. Assign CPT code 23410 or 23412 for repairs involving
manipulation
of a frozen
shoulder.
Chronic
tears
originate
fromcode
over-use or
one or two tendons
or major
muscles of
the rotator
cuff.
Assign CPT
constant
stress.
CPT code
23410
or 23412
for repairs
involving
23420 for
a repairAssign
of a complete
shoulder
(rotator)
cuff avulsion,
referring
to
theorrepair
all threeormajor
muscles/tendons
of rotator
the shoulder
Source:
one
two of
tendons
major
muscles of the
cuff. cuff.
Assign
CPT code
February
CPT
newsletter,
AMA.
23420
for a2002
repair
ofAssistant
a complete
shoulder
(rotator) cuff avulsion, referring to
the repair of all three major muscles/tendons of the shoulder cuff. Source:
February
2002
CPT
Assistant
Clinical Tip:
The
major
musclesnewsletter,
of the rotatorAMA.
cuff: supraspinatus,
infraspinatus and teres minor.
Clinical Tip: The major muscles of the rotator cuff: supraspinatus,
infraspinatus and teres minor.
Coding Resource:
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
11
EXHIBIT A
Arthroscopic Coding Guidelines
Arthroscopic Coding Guidelines
D. Limited versus Extensive Arthroscopic Shoulder Debridement
Code 29822 describes limited arthroscopic shoulder debridement, while
code 29823 a describes extensive arthroscopic shoulder debridement. The
D. facility
Limited
versus
Extensive
Arthroscopic
Shoulder
Debridement
needs
to develop
a guideline
that defines limited
versus extensive
.
Code 29822 describes limited arthroscopic shoulder debridement, while
code 29823 a describes extensive arthroscopic shoulder debridement. The
facility needs to develop a guideline that defines limited versus extensive .
CASE
29822-RT
(Limited
CASESTUDY:
STUDY:
29822-RT
(Limited
Debridement)
Debridement)
Preoperative
Diagnosis:
Preoperative
Diagnosis:
Painful
rightright
shoulder.
Painful
shoulder.
Postoperative Diagnosis:Posterior superior labral tear with internal
Postoperative
Diagnosis:Posterior
superior labral tear with internal
impingement
of the
right shoulder.
impingement of the right shoulder.
Operation: Evaluation under anesthesia, arthroscopy, arthroscopic
Operation:ofEvaluation
under anesthesia,
debridement
superior posterior
labral tear. arthroscopy, arthroscopic
debridement of superior posterior labral tear.
Anesthesia: General endotracheal.
Anesthesia: General endotracheal.
Operative Note: After adequate general endotracheal anesthesia was
obtained,
theNote:
patient’s
right
shouldergeneral
was examined.
She was
found to was
Operative
After
adequate
endotracheal
anesthesia
have
no anterior,
posteriorright
or inferior
instability
of the shoulder.
obtained,
the patient’s
shoulder
was examined.
She The
was found to
shoulder
compared
with the
left shoulder
and these
symmetrical.
have nowas
anterior,
posterior
or inferior
instability
of thewere
shoulder.
The
The patient was placed inthe left lateral decubitus position with good axillary
shoulder on
was
compared
with
theand
left neck
shoulder
and these were
symmetrical.
clearance
a bean
bag with
head
in neutralposition.
After
sterile
Theand
patient
was
inthe leftwas
lateral
decubitus position
good axillary
prep
drape,
theplaced
right shoulder
arthroscoped
through with
standard
clearance
on
a
bean
bag
with
head
and
neck
in
neutralposition.
anterior anposterior portals. The anterior portal was made inside out After sterile
prep and
thespace.
right shoulder
was
through
thedrape,
triangular
The patient
wasarthroscoped
noted to have athrough
healthy standard
anterior
anposterior
portals.
The
anterior
portalsmooth.
was made inside out
glenoid
and
humeral head.
These
were
completely
through the triangular space. The patient was noted to have a healthy
glenoid and humeral head. These were completely smooth.
12
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
CASE STUDY: 29822-RT (Limited
CASE STUDY: 29822-RT (Limited
Debridement)
Debridement)
The biceps was probed and was stable. There was no evidence of SLAP
The biceps
was probed
and of
was
stable.
Therehealthy
was no and
evidence
of SLAP
lesion.
The under
surface
the
cuff was
normal
and no
lesion. The under surface of the cuff was healthy and normal and no
evidence
of
any
tears,
erythema
or
inflammation.
The
posterior
superior
evidence of any tears, erythema or inflammation. The posterior superior
labrum
had
tear. ItItwas
was
unstable.
It debrided
was debrided
labrum
hadaasmall
small tear.
notnot
unstable.
It was
with a with a
shaver.
andposterior
posterior
ligaments
checked
and
were intact
shaver.The
Theanterior
anterior and
ligaments
werewere
checked
and were
intact
all the
wayaround
around to
to the
head.
WithWith
full external
rotation,
there there
all the
way
thehumeral
humeral
head.
full external
rotation,
evidenceof
ofpinching
pinching ofofthe
posterior
superior
labrum
but again
waswas
evidence
the
posterior
superior
labrum
butno
again no
instability.The
Theanterior
anterior glenohumeral
ligament
complex
was intact,
probed
instability.
glenohumeral
ligament
complex
was
intact, probed
and was quite stable. The shoulder was re-arthroscoped through the
andanterior
was quite
was
re-arthroscoped
through
the
portal.stable.
BicepsThe
was shoulder
checked and
was
stable and healthy.
There was
anterior
portal.of Biceps
was checked
and was
stable
and healthy.
There was
no evidence
any inflammation
as it passed
through
the groove.
The
no posterior
evidence
ofwas
anyintact
inflammation
asNo
it passed
through the
groove.
cuff
and healthy.
other abnormalities
were
noted. The
The arthroscope
inflow
cannula
wereNo
then
placed
in the subacromial
posterior
cuff wasand
intact
and
healthy.
other
abnormalities
were noted.
which wasand
quiteinflow
healthy.
There was
no then
redness,
erythema
Thespace
arthroscope
cannula
were
placed
in theorsubacromial
inflammation.
Thequite
bursahealthy.
was smooth
and was
thin. no
Superior
surface
of the cuff
space
which was
There
redness,
erythema
or
was intact. The under surface of the acromion was healthy without any
inflammation.
The
bursa
was
smooth
and
thin.
Superior
surface
fraying. The CA ligament was healthy and normal without any evidence ofof the cuff
wasinflammation.
intact. TheThis
under
the acromion
was healthy
without any
wassurface
checkedof
through
both the posterior
and anterior
fraying.
The
ligamentwere
wasnoted
healthy
and
normal without
any evidence of
portals.
No CA
abnormalities
in the
subacromial
space. The
arthroscope and
were
removed.
Thethe
portals
were closed
with
inflammation.
Thisinflow
wascannula
checked
through
both
posterior
and anterior
buriedNo
4-0abnormalities
Vicryl. Sterile dressing
was applied.
patient wasspace.
then
portals.
were noted
in the The
subacromial
The
awakened and taken to the recovery room in satisfactory condition.
arthroscope
and inflow cannula were removed. The portals were closed with
buried 4-0 Vicryl. Sterile dressing was applied. The patient was then
awakened and taken to the recovery room in satisfactory condition.
CASE
STUDY:29826-RT,
29826-RT,
CASE STUDY:
29823-RT (Extensive
(Extensive Debridement)
29823-RT
Debridement)
Anesthesia:
Generalendotracheal
endotracheal tube
Anesthesia:
General
tube
Preoperative Diagnosis:
Preoperative
Diagnosis:
1. Posterior
labral tear, question clinical significance.
1. 2. Posterior
labral
tear, question clinical significance.
Subacromial
impingement.
2. Subacromial impingement.
Postoperative Diagnosis:
1. Posterior/inferior
Postoperative
Diagnosis:labral tear.
Anterior/superior labral
labral tear.
1. 2. Posterior/inferior
tear.
Subacromial impingement.
2. 3. Anterior/superior
labral tear.
3. Subacromial impingement.
Procedure Performed:
1. Exam under anesthesia.
Procedure
Performed:
2. Diagnostic
arthroscopy of glenohumeral joint
1. 3. Exam
under anesthesia.
Debridement
of anterior/superior and posterior/inferior labral tears.
Arthroscopic
subacromial
2. 4. Diagnostic
arthroscopy
ofdecompression.
glenohumeral joint
3. Debridement of anterior/superior and posterior/inferior labral tears.
Complications:
None
4. Arthroscopic subacromial
decompression.
Complications:
None
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
13
EXHIBIT A
CASE STUDY: 29826-RT,
CASE STUDY: 29826-RT,
29823-RT
(ExtensiveDebridement)
Debridement)
29823-RT (Extensive
Operative Findings:
Operative Findings:
1. Intact
humeral articular cartilage.
1. Intact humeral articular cartilage.
2. Small
defect,posterior/inferior
posterior/inferior
glenoid,
adjacent
to
2. Smallosteochondral
osteochondral defect,
glenoid,
adjacent
to
degenerative
the posterior
posteriorlabrum.
labrum.
degenerativefraying
fraying of
of the
3.Posterior/inferior
tearwithout
withoutfrank
frank
detachment
periosteal
3.Posterior/inferior labral
labral tear
detachment
and and
periosteal
strippingofofthe
theposterior
posterior labrum
fraying
nearnear
its insertion,
stripping
labrumwith
withdegenerative
degenerative
fraying
its insertion,
onto
theglenoid.
glenoid.
onto
the
4. Degenerativetearing
tearing of
labrum
withwith
stable
4. Degenerative
of the
theanterior/superior
anterior/superior
labrum
stable
superior/anterior labrum.
superior/anterior labrum.
5. Intact anterior/inferior and posterior/superior labrum.
5. Intact
anterior/inferior and posterior/superior labrum.
6. Intact biceps tendon with stable biceps labral anchor.
6. Intact
biceps
withbursal
stablesurface.
biceps labral anchor.
7. Intact
rotatortendon
cuff from
7. Intact
rotator
cuff
from
bursal
surface.
8. Subacromial bursal thickening synovitis.
8. Subacromial
bursal
thickening
synovitis.
9. Large spur on
surface
of acromion.
10. Fullspur
rangeon
ofsurface
motion ofofthe
glenohumeral joint.
9. Large
acromion.
Stable
glenohumeral
examination
with 2+ anterior
10.11.
Full
range
of motion of
the glenohumeral
joint. translation and
tightened to 0+ with progressive external rotation.
11. Stable glenohumeral examination with 2+ anterior translation and
12. No discernible posterior translation.
tightened
to 0+ with progressive external rotation.
12. No discernible posterior translation.
CASE STUDY:
CASE
STUDY:29826-RT,
29826-RT,
29823-RT (Extensive
29823-RT
(ExtensiveDebridement)
Debridement)
Operative Indications:The patient is a 38-year-old who injured himself
Operative
Indications:The
patient
is the
a 38-year-old
who
injured
himself
playing basketball.
He has had
pain in
right shoulder.
This
has been
playing
basketball.
He has
had pain in Risks
the right
This
has been
refractory
to conservative
management.
and shoulder.
benefits of the
above
listed procedure
was discussed
with the patient
who
understood
risksabove
as
refractory
to conservative
management.
Risks
and
benefits the
of the
wellprocedure
as benefits was
and signed
the informed
consent
form. the risks as
listed
discussed
with thepreoperative
patient who
understood
well as benefits and signed the informed preoperative consent form.
Operative Description in Detail: The patient was brought to the operating
room.General endotracheal anesthesia induced. He was examined under
Operative
Description
Detail:
patient
brought
anesthesia
and findings in
were
noted The
as above.
Hewas
has a
stable to the operating
room.General
anesthesia
induced.
wasdecubitus
examined under
glenohumeralendotracheal
examination. He
was positioned
in theHe
lateral
anesthesia
and
notedThe
as above.
He haswas
a stable
position with
thefindings
left sidewere
downward.
right shoulder
placed in the
Arthrex shoulder
holder, prepped
and positioned
draped in a in
standard
fashion.
glenohumeral
examination.
He was
the lateral
decubitus
Standard
arthroscopic
portals
were established
posteriorly
andwas
anteriorly.
position
with
the left side
downward.
The right
shoulder
placed in the
Diagnostic
arthroscopy
carriedand
through
the portal
with findings
as noted
Arthrex
shoulder
holder,was
prepped
draped
in a standard
fashion.
above. The
anterior/superior
labral
tear was debrided.
The arthroscope
Standard
arthroscopic
portals
were
established
posteriorly
and
anteriorly.
was redirected anteriorly. The posterior labral tear was then debrided.
Diagnostic
arthroscopy
through
the portal with findings as noted
The posterior
labral tearwas
was carried
then probed
aggressively.
above. The anterior/superior labral tear was debrided. The arthroscope
was redirected anteriorly. The posterior labral tear was then debrided.
The posterior labral tear was then probed aggressively.
14
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
CASE
29826-RT,
CASE STUDY:
STUDY: 29826-RT,
29823-RT
Debridement)
29823-RT (Extensive
(Extensive Debridement)
no evidenceofofperiosteal
periosteal stripping.
It was
just just
a flapatear
the
ThereThere
waswas
no evidence
stripping.
It was
flapthrough
tear through
the
labrum
adjacenttotothe
the osteochondral
defect.
AfterAfter
debridement
of both of both
labrum
that that
waswas
adjacent
osteochondral
defect.
debridement
the osteochondral
defectand
and the
thethe
remaining
labrum
was stable,
the osteochondral
defect
thelabral
labraltear,
tear,
remaining
labrum
was stable,
there was no evidence of posterior instability. The anterior/superior tear was
there was no evidence of posterior instability. The anterior/superior tear was
debrided, once again was felt not to be amenable for repair. The arthroscope
debrided,
once again
felt notspace.
to be Aamenable
for repair.
was reentered
into thewas
subacromial
standard lateral
portal wasThe arthroscope
was reentered
subacromial
space.
A standard
portal
was
established into
at thethe
junction
of the anterior
middle
third of the lateral
acromion.
A 5.5
sternal resector
and Arthrocare
were middle
then used
throughout
the procedureAfor
established
at the junction
of thewand
anterior
third
of the acromion.
5.5
subacromial
decompression.
A 5.5 barrel
was
usedthroughout
to perform the procedure for
sternal
resector and
Arthrocare wand
werebur
then
used
acromioplasty until the anterior third of the acromion was up in the middle and
subacromial
decompression.
5.5 barrel bur
usedmultiple
to perform
posterior thirds.
Adequacy of theAacromioplasty
waswas
checked
times and
acromioplasty
the anterior
third of
was
in the
middle
deemed to beuntil
acceptable.
The rotator
cuffthe
wasacromion
probed from
theup
bursal
surface
and and
no evidence
cuff tear. The
removed from
shoulder
and attention
posterior
thirds. ofAdequacy
of arthroscope
the acromioplasty
was the
checked
multiple
times and
turned
closing. The
subacromial
space
portal
sites were
with _%
deemed
to towards
be acceptable.
The
rotator cuff
was
probed
frominjected
the bursal
surface and
Marcaineof
with
Epinephrine.
port sites were
closed with
nylon and
sutures.
no evidence
cuff
tear. TheThe
arthroscope
removed
frominterrupted
the shoulder
attention
Sterile dressing consisting of Betadine soaked Adaptic, 4 x 4s and Elastoplast was
turned
towards
The
space
sites
were
injected with _%
placed
on theclosing.
shoulder.
Thesubacromial
patient was placed
in aportal
sling an
swath,
awakened,
Marcaine
with and
Epinephrine.
port room
sitesinwere
with
extubated,
taken to theThe
recovery
stableclosed
condition.
Heinterrupted
tolerated thenylon sutures.
procedure
well.
There were
complications.
Sterile
dressing
consisting
ofno
Betadine
soaked Adaptic, 4 x 4s and Elastoplast was
placed on the shoulder. The patient was placed in a sling an swath, awakened,
extubated, and taken to the recovery room in stable condition. He tolerated the
procedure well. There were no complications.
Arthroscopic Coding Guidelines
Arthroscopic Coding Guidelines
E. Postoperative Pain Management
E. Postoperative Pain Management
October 2001 CPT Assistant newsletter, AMA:
October 2001 CPT Assistant newsletter, AMA:
• • When
general anesthesia is administered and pain management injections are
When general anesthesia is administered and pain management injections are
performed
analgesia,
they
separate
and distinct
services
performedtotoprovide
provide postoperative
postoperative analgesia,
they
are are
separate
and distinct
services
and
are
reported
tothe
theanesthesia
anesthesia
code.
Whether
the block
procedure
and
are
reportedin
in addition
addition to
code.
Whether
the block
procedure
(insertion
narcotic
local
anesthetic
agent)
(insertionofofcatheter,
catheter, injection
injection ofofnarcotic
or or
local
anesthetic
agent)
occursoccurs
preoperatively,
during
procedure
is immaterial.
preoperatively,postoperatively,
postoperatively, ororduring
thethe
procedure
is immaterial.
If, on
theother
otherhand,
hand, the block
is used
primarily
for the
itself, itself,
• • If, on
the
blockprocedure
procedure
is used
primarily
foranesthesia
the anesthesia
serviceshould
should be
be reported
reported using
anesthesia
code
alone.
In a combined
thethe
service
usingthe
the
anesthesia
code
alone.
In a combined
epidural/generalanesthetic,
anesthetic, the
be be
reported
separately.
epidural/general
theblock
blockcannot
cannot
reported
separately.
Example:
Example:
[NOTE: Many third-party payers do not accept CPT anesthesia codes from hospitals.]
•
Many
third-party
do not accept
anesthesia brachial
codes from
hospitals.]
• [NOTE:
Shoulder
surgery
couldpayers
be performed
under CPT
an interscalene
plexus
block
Shoulder
surgery
could postoperative
be performedanalgesia.
under anThis
interscalene
brachialusing
plexus
that would
also provide
would be reported
the block
anesthetic
codeprovide
(e.g., 01620).
If the block
were intended
to reported
alleviate using the
that
would also
postoperative
analgesia.
Thisprimarily
would be
postsurgical
pain,
and
a
general
anesthetic
was
administered
for
the
shoulder
anesthetic code (e.g., 01620). If the block were intended primarily to alleviate
procedure, the
block
be separately
reportable.
postsurgical
pain,
andwould
a general
anesthetic
was administered for the shoulder
procedure, the block would be separately reportable.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
15
EXHIBIT A
CASE STUDY: 29826-RT, 23120,
64415-59 (Post Op Pain Block)
OPERATIVE REPORT
DATE: 12/01/200X
PREOPERATIVE DIAGNOSIS:
Possible rotator cuff tendonitis, acromioclavicular arthritis, and frozen
shoulder, right shoulder.
POSTOPERATIVE DIAGNOSIS:
Frozen shoulder, subacromial bursitis-impingement, and acromioclavicular
arthritis, right shoulder.
OPERATIVE PROCEDURE:
Arthroscopic subacromial decompression with open distal clavicle resection
and manipulation under anesthesia, right shoulder.
SURGEON:
ASSISTANT:
CASE STUDY:
23120,
CASE
STUDY:29826-RT,
29826-RT,
23120,
64415-59 (Post
Block)
64415-59
(PostOp
OpPain
Pain
Block)
INDICATION FOR PROCEDURE: The patient is a 51-year-old male with recalcitrant
shoulder painFOR
and aPROCEDURE:
frozen shoulder. The
He had
failedisrehabilitative
andmale
injection
INDICATION
patient
a 51-year-old
with recalcitrant
treatments
requested
intervention.
shoulder
painand
and
a frozenoperative
shoulder.
He had failed rehabilitative and injection
treatments and requested operative intervention.
FINDINGS AT OPERATION: Preop motion was 90 degrees of flexion and 30
degrees of external and internal rotation. There was significant subacromial bursitis
FINDINGS
AT OPERATION:
Preop
motion
was
90 degreesspur.
of flexion
and 30
with very thickened
coracoacromial
ligament
and
a subacromial
The intradegrees
external were
and internal
articularofstructures
normal. rotation. There was significant subacromial bursitis
with very thickened coracoacromial ligament and a subacromial spur. The intraarticular
structures were normal.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite
and general anesthesia was smoothly induced. The shoulder was examined and
interscalene
block
placedsuite
the above notedOF
limitation
of motion was
found.
Anwas
DESCRIPTION
PROCEDURE:
The
patient
brought to
the was
operative
forgeneral
postop pain
control and
patient was
placed in
theshoulder
beach chair
The
wasposition.
examined and
and
anesthesia
wasthe
smoothly
induced.
right noted
shoulder
was manipulated
with palpable
and audible
crepitaceblock
into 150
was
theThe
above
limitation
of motion
found.
degrees
of elevation,
external
rotation was
was to
80 withAn
theinterscalene
opposite shoulder
being
90,placed
forand
postop
pain
control
and the patient
was placed
in the beach
chair position.
internal
rotation
was equivalent
at 70. Adduction
and abduction
were equivalent.
The
right
shoulder
manipulated
and audible
into 150
The
shoulder
was was
prepped
and drapedwith
in a palpable
sterile fashion.
Throughcrepitace
anterolateral,
degrees
of elevation,
external rotation
wasshoulder
to 80 with
opposite
direct lateral,
and posterolateral
portals, the
wasthe
examined
andshoulder
treated being 90,
arthroscopically.
joint
was
entered. The
humeral
and
internal rotationThe
wasglenohumeral
equivalent at
70.
Adduction
andglenoid,
abduction
werehead,
equivalent.
biceps
tendon,
andprepped
labrum were
cuff
was intact.
The
shoulder
was
and intact.
drapedThe
in arotator
sterile
fashion.
Through anterolateral,
direct lateral, and posterolateral portals, the shoulder was examined and treated
arthroscopically. The glenohumeral joint was entered. The glenoid, humeral head,
biceps tendon, and labrum were intact. The rotator cuff was intact.
16
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
CASE STUDY: 29826-RT, 23120,
64415-59 (Post Op Pain Block)
The arthroscopic instruments were placed in the subacromial space. The
bursa was resected. The coracoacromial ligament was released from
the acromion with the cautery. Utilizing a bur and a shaver, the acromion
was flattened .
The anterior portion was excised and the rotator cuff was found to have a
significant partial-thickness bursal side tear, but no full-thickness tear and
the arthroscopic instruments were removed. A small incision was
made over the distal clavicle. The deltoidtrapezial raphe was taken down
in a subperiosteal fashion off of the distal clavicle and the distal 2.5 cm of
clavicle was excised with a saw. Bone wax was placed over the cut end.
The deltotrapezial raphe was closed with #1 Nurolon. A small closed
suction drain was placed and the wound was closed with 2-0 Vicryl and a
Monocryl for the skin. Steri-Strips were applied. The acromioplasty was
checked manually before closure. A sterile compressive dressing was
applied. The patient was awakened and taken to the recovery room in good
condition. There were no complications. Blood loss was minimal.
Postoperative plans are to rehabilitate the patient’s shoulder.
CASE STUDY: 29826-RT, 29827-RT
OPERATIVE REPORT
OPERATION: Arthroscopic acromioplasty and arthroscopic rotator cuff repair, right
shoulder.
ANESTHESIA: Scalene block.
PREOPERATIVE DIAGNOSIS: Full thickness rotator cuff tear, supraspinatus
insertion site with impingement syndrome of the right shoulder.
POSTOPERATIVE DIAGNOSIS: Full thickness rotator cuff tear, supraspinatus
insertion site with impingement syndrome of the right shoulder.
OPERATIVE PROCEDURE: The patient was brought to the operative suite, scalene
block right shoulder followed by intravenous sedation anesthesia performed. The
right shoulder was examined and demonstrated full passive loss of shoulder motion.
The patient was then placed in the supine beach chair position and the right shoulder
was prepped and draped in the usual sterile fashion. A 30-degree arthroscope was
introduced through the posterior portal, intra-articular structures were visualized
demonstrating significant synovitis at the rotator interval and superior aspect of
the cuff.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
17
EXHIBIT A
CASE STUDY: 29826-RT, 29827-RT
This area was initially cauterized and then debrided with the full radius
resector. Hemostasis was achieved. The long head of the biceps also had
synovitis at its intra-articular portion under the cuff tear. There was no
fraying or fibrillation of the biceps. The area of hyperemia was also
cauterized. The superior glenoid labrum was intact. There was some
degree of fraying and fibrillation in this area but no evidence for a type 2
slap lesion. Anterior-inferior capsule labrum, posterior-inferior capsule
labrum were normal. Humeral head and articular surfaces of the glenoid
and humeral head were normal. There was full thickness tear of the
supraspinatus insertion site over approximately a 3 cm area from the rotator
interval to the posterior-superior corner of the greater tuberosity. The tear
was retracted to approximately the mid humeral head. The biceps tendon
anchor and bicipital groove were normal, subscapularis was normal and
posterior cuff was normal. The arthroscope was then placed in the
subacromial space, there was marked bursal thickening and hypertrophy.
A partial bursectomy was carried out, there were some minor changes on
the undersurface of the acromion. Soft tissue was removed from the
acromion with the cautery device and shaver. A minimal acromioplasty
was required, plus 3 to 4 mm of bone anteriorly and tapering this
posteriorly. The acromioclavicular joint was visualized but not resected.
The soft tissue was removed from the greater tuberosity, a bone trough was
made over the greater tuberosity from the bicipital groove to the posterior
most extent of the cuff. This was approximately a 2 to 2.5 cm bone trough.
CASE STUDY: 29826-RT, 29827-RT
The cuff was mobilized by release of the intra-articular portion of the
capsule, release of the coracohumeral ligament at the base of the coracoid.
This was done with a cautery device.
The cuff was then mobilized and pulled to the bone trough, two 5 mm
Arthrex anchors were placed in the lateral most aspect of the bone
trough, and the sutures were tied with three simple sutures and one
mattress suture. An excellent anatomic repair was achieved with the
cuff being opposed to the tuberosity with firm fixation. The
arthroscopic equipment was removed from the shoulder, the portal sites
were closed with #3-0 Prolene and Steri-Strips. Sterile dressings were
applied. The patient was reversed from anesthetic and brought to the
recovery room in stable and satisfactory condition.
COMPLICATIONS: None.
18
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
CASE STUDY: 29807-RT, 29826-RT,
29824-RT
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:
1. Acromioclavicular joint arthritis right shoulder.
2. Possible superior labrum anterior and posterior lesion or labrum tear
right shoulder.
POSTOPERATIVE DIAGNOSIS:
1. Osteoarthritis right acromioclavicular joint.
2. Anterior superior labrum anterior and posterior lesion right shoulder.
TITLE OF THE OPERATION:
1. Arthroscopic superior labrum anterior and posterior lesion repair with one
3.0 mm Fast-Tac suture anchor.
2. Arthroscopic distal clavicle excision right shoulder.
ANESTHESIA: General.
CASE STUDY: 29807-RT, 29826-RT,
29824-RT
PREOPERATIVE NOTE: The patient is a 57-year-old gentleman with a
long history of right shoulder pain. Preoperative evaluation indicated pain
emanating from an arthritic AC joint, and we suspected a SLAP lesion as
well. We did not suspect the rotator cuff or impingement. Therefore, the
above procedure was recommended.
DETAILS OF THE PROCEDURE:
Under general anesthetic, the patient was placed supine in the semi-sitting
position with the head on a Mayfield headrest. The right shoulder was
scrubbed, prepped and draped in the usual manner. The posterior viewing
scrubbed, prepped and draped in the usual manner. The posterior viewing
portals were established through the glenohumeral joint. The articular
cartilage in the glenoid and humeral sides was normal. The posterior
labrum and direct superior labrum was normal. However, the anterior
superior labrum was detached. There was a SLAP lesion under the
biceps anchored anteriorly coming down to the approximately 1 o’clock.
We probed this through an anterior portal in the rotator interval and found
this to be true. The biceps tendon anchor was normal except for the
anterior portion of the anterior superior labrum. The biceps tendon exited
the joint normally. The rotator cuff was normal.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
19
EXHIBIT A
CASE STUDY: 29807-RT, 29826-RT,
29824-RT
We prepared the anterior superior glenoid neck with a shaver and a
bur after using the periosteal elevator to mobilize the soft tissue. Next, we
placed a single 3.0 Bio Fast-Tac suture anchor at approximately 12:30 on
the anterior superior glenoid rim. We used standard arthroscopic knot
tying techniques to tie down the anterior superior labrum with the
anterior portion of the biceps anchor. Fortunately, the majority of the
biceps anchor was intact. We had established this using a peel-back sign
intraoperatively. Once the labrum was repaired, we probed it and found it
to be stable.
Next, the subacromial space was entered. A lateral working portal was
established. We excised enough of the subacromial bursa to visualize
the anterior acromion. We denuded the anterior acromion across to the AC
joint removing the inferior AC joint ligaments. The distal clavicle was
clearly identified. We removed the osteophyte on the medial end of the
anterior acromion, which was in part partial of the AC joint osteophyte. We
then did approximately an 8 mm distal clavicle excision through the same
anterior portal that we used for the labrum repair by redirecting it directly
into the AC joint. We removed all the clavicle up to, but not including
the superior AC joint ligaments.
CASE STUDY: 29807-RT, 29826-RT,
29824-RT
Next, the arthroscopic instruments were removed. The portals were closed
with 4-0 nylon. A sterile dressing was applied followed by a Don Joy
shoulder immobilizer. Sponge and instrument counts are correct. The
patient tolerated the procedure well and was transferred to the recovery
room in satisfactory condition.
POSTOPERATIVE PLAN: The patient will be discharged home today and I
will see him in the office in a few days time for follow-up.
20
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
CASE STUDY: 29806-LT, 29807-59LT
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Recurrent anterior instability of the left
shoulder
POSTOPERATIVE DIAGNOSIS: Recurrent anterior instability of the left
shoulder with Bankart lesion and SLAP lesion ( superior labrum anterior and
posterior )
OPERATION: Evaluation under anesthesia, arthroscopy, arthroscopic
Bankart repair and SLAP repair
ANESTHESIA: General endotracheal
CASE STUDY: 29806-LT, 29807-59LT
OPERATIVE NOTE: After adequate general endotracheal anesthesia
was obtained, the patient’s shoulders were examined. The left shoulder
was easily subluxable. The right shoulder was stable. There was no
posterior or inferior instability of either shoulder. The patient was placed in
the right lateral decubitus position with good axillary clearance on the bean
bag with the head and neck in neutral position. Peroneal nerve on the right
leg was cleared. After sterile prep and drape, the shoulder was placed in 12
pounds of traction and arthroscoped through standard posterior and anterior
portals. The anterior portal was made inside out through the triangular
space. A second accessory portal was made just above the subscapularis
tendon. The patient was noted to have an intact humeral head with minimal
chondromalacia. The glenoid was intact. The anterior and superior labrum
were torn. There was some fraying along the posterior labrum. This was
probed and was stable though. The superior labrum was hypermobile
consistent with a type 2 SLAP lesion and anteriorly, the patient had a
Bankart lesion..
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
21
EXHIBIT A
CASE STUDY: 29806-LT, 29807-59LT
This anterior Bankart lesion was probed and was detached. The capsule
labral complex although was reasonably healthy other than this lesion. The
rotator cuff and biceps were intact. The capsule labral complex was
released off the scar tissue of the anterior neck with an elevator, cleaned
with a shaver and a bur was used to create a good bleeding bed along
the anterior and superior aspects of the glenoid. The Bankart was then
repaired using two Suretacs and SLAP lesion was repaired with an
Acufex suture anchor superiorly. Once this was done, everything was
probed was quite stable. The heads of the Suretacs were smoothed down
to the level of the glenoid. The arthroscope and inflow cannula were
removed. The portals were closed with buried 4-0 Vicryl. The patient was
placed in a shoulder immobilizer after placing a sterile dressing. He was
then awakened and taken to the recovery room in satisfactory condition.
Resources
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
22
www.aaos.org
www.aaos.org/wordhtml/bulletin/archive.asp
www.arthroscopy.com
www.animatedmedical.com
www.orthosupersite.com
www.ortho.hyperguides.com
www.vh.org.adult/provider/anatomy/atlasofanatomy
www.fpnotebook.com/ORT.htm
www.gpoaccess.gov/fr
www.hope.edu/academic/kniesiology/athtrain/program/studentprojects/
fischer/sld001.htm (animated bankhart repair)
www.cms.hhs.gov
www.ama-assn.org
www.ntis.gov/product/correct-coding.htm
www.assh.org
www.medscape.com/homeindex?src=hdr
www.nlm.nih.gov/medlineplus/encyclopedia.html
www.ortho.hyperguides.com
www.cdc.gov
www.oig.hhs.gov
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
EXHIBIT A
Disclaimer
The purpose of these handouts is to accompany the presentations conducted by
Susan Vogelberger, CPC, CPC-H. There is no guarantee that the use of this
publication will prevent differences of opinion with providers or insurance carriers
regarding reimbursement issues. Ms. Vogelberger, or any third party sponsor,
provided nor implied or expressed warranty regarding the content of this seminar
and/or publication due to the constant changing of regulations, laws and policies.
It is further noted that any and all liability arising from the use of this publication
and/or information supplied at this seminar is the sole responsibility of the
participant, and their respective employers, who by purchase of this publication
and/or attendance at this seminar evidences agreement to hold harmless the
aforementioned parties, their employees and affiliates. The intent of this
publication is to be used as a teaching tool accompanying the oral presentation
only. The use of copyrighted pages are reprinted with permission and/or fall
under “Fair Use” as referenced in the US Copyright Law, Chapter 1, Section 107.
Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
23
Resources
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Shoulder Coding Strategies for ASCs: How to obtain maximum reimbursement
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RESOURCES
Speaker resources
Lolita M. Jones, RHIA, CCS
Lolita M. Jones Consulting Services
1921 Taylor Avenue
Fort Washington, MD 20744
Phone: 301/292-8027
Fax: 301/292-8244
E-mail: LolitaMJ@aol.com
Susan Vogelberger, CPC, CPC-H
The Orthopeadic Surgery Center At Beeghly Medical
6505 Market Street, Building B
Suite 101
Boardman, OH 44512-3458
Phone: 330/758-1065
E-mail: susanv.hcce@zoominternet.net
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