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Insight: Superior Capsular Reconstruction & Rotator Cuff Repair
concept, the individual surgical procedures have established diagnostic and procedural codes. When the surgeon performs both procedures, we recommend 29827 for coding of rotator cuff repair and 29806 for capsular reconstruction.
In a SCR, the surgeon may use autograft or allograft tissue to reconstruct or repair deficient capsular tissues. As such, they should report 29806 when the technique is performed arthroscopically. If the surgeon also performs an arthroscopic repair, the residual rotator cuff tissue (complete or partial) 29827 should also be reported.
The surgeon should be sure to document restoration of the deficient superior capsular tissue and reduction of superior subluxation of the glenohumeral joint. The surgeon should also be sure to document the details of their repair of the rotator cuff tissue.
-In summary the above procedure, for myself, is currently coded as 29827, 29806-59 and when using dermal matrix for soft tissue reinforcement 17999 is applied. There is not a lot of documentation regarding the correct coding of the procedure described above; my question is how is it being coded within the Ortho community, and how are you handling denials for the portion 29806 represents? Am I not correct in splitting the superior capsular reconstruction from the rotator cuff repair, and is the biological implant for soft tissue reinforcement considered inclusive? If so, please direct me to supporting documentation.
Open subscapularis tendon and rotator cuff repair
Operation Performed: Arthroscopy, Labral Debridement, Subacromial Decompression with Open Repair of Subscapularis Tendon, Biceps Tenodesis, and rotator cuff repair, right shoulder
Post operative diagnosis: Full Tear of subscapularis tendon with avulsion, dislocation biceps tendon with a 2.5 cm tear rotator cuff, and impingement syndrome
CPT 23412 [Subscapularis and Rotator Cuff]
CPT 23430 [Biceps Tenodesis]
CPT 29823 [Labral Debridement]
CPT 29826 [Subacromial Decompression]
After the scope procedures, a 4-cm incision was made between the anterior and lateral portals, Subscapularis was completely avulsed, Bed of bone prepared and fixed in 2 row technique. Prior to this biceps tenodesis was done with Arthrex biceps tenodesis Tightrope. Subscapularis was reapproximated with 2 Corkscrew anchors, double armed mattress stitches to take it to the soft tissue fibers which were anterior portion of greater tuberosity. Rotator cuff tear was identified. Bed of bone had been prepared. It was freshened. It was fixed in a 2-row technique. The medial row was 2 corkscrew anchors, double-armed mattress stitches and then 1 Swivelock which gave a watertight closure…
Our doctors are doing a lot of subscapularis tendon repairs and not sure about coding this tendon separately since it is the rotator cuff
Arthroscopic shoulder procedure w/open rotator cuff repair
Am I understanding this or am I way off…
Want to code this way: 23410-LT 29828-59, 29826-59 and 29823. Not use 29820
29828, 29826 29823 (NCCI edit Presence of an anatomic site modifier on this code(s) 23410 is suppressing NCCI edit. Check documentation to determine whether both code pair(s) can be billed or an additional site modifier added)
29820 (NCCI Edit.. Code 2 of a code pair with 29828 29823 that would be allowed if an approp. NCCI modifier were present.)
DX: Acute massive RTC tear, bicep tenosynovitis, labral fraying with impingement, synovitis of the glenohumeral joint
Surgery: Arthroscopy left shoulder w/extensive debridement of the labrum, partial synovectomy, subacromial decompression with acromioplasty with bicep tenodesis and open acute roatator cuff repair
PROCEDURE:
introduced the trocar into the glenohumeral joint atraumatically and began a diagnostic arthroscopy, which demonstrated a
massive rotator cuff tear, biceps tenosynovitis with a torn labrum at the biceps insertion synovitis through the shoulder.
I performed a biceps tenotomy, which was later repaired. I debrided the stump of the biceps, utilized a shaver to circumferentially debride the labrum, and then utilized a Werewolf RF to perform a partial synovectomy of the glenohumeral joint. Once completed, I then placed the scope into the subacromial space. I started a standard anterior lateral portal and with the use of a Werewolf and shaver,
performed a subacromial decompression and bursectomy. I then identified a large spur on the acromion and performed an acromioplasty with a burr, co-planing it with the AC joint. Once completed, I then made the decision to open the rotator cuff. I then extended my
anterior lateral portal superiorly and slightly inferiorly, dissected down through the subcutaneous tissue with scissor dissection and elevated medial and lateral flaps over the deltoid fascia and then split the deltoid and the raphe between the anterior and lateral delts. I then placed a Link retractor. I identified the bicipital groove by externally rotating. I incised the transverse ligament and the pulled the biceps through the incision. I then placed a 1.8 mm Q-Fix anchor at the top of the bicipital groove. I rasped the entire groove and then whipstitched the biceps tendon with the suture from the Q-Fix. I reduced it within the bicipital groove and then tied knots over the top. I then utilized
the remaining suture to repair the transverse ligament. I then identified the massive rotator cuff tear. I debrided the insertion with a rasp and rongeur and got down to a bed of good bleeding bone and then placed three 5.5 Healicoil suture anchors along the articular margin. Each one had good bite. I then sequentially passed all twelve sutures through the rotator cuff in standard fashion. I then reduced the cuff down to the insertion and tied medial row knots. I then placed one suture from each one of the knots in an anterior lateral 5.5 mm MultiFIX-S Ultra suture anchor for my lateral row, reduced the cuff back down to the insertion very well and then repeated those same steps with the
more posterior lateral 5.5 MultiFIX-S Ultra. Overall, I was extremely happy with the reduction of the rotator cuff and the overall repair. I then thoroughly irrigated out the wound. I documented the repair with a picture and then closed the deltoid fascia with running #0 Vicryl. The subcutaneous layer was then closed with a #2-0 Vicryl and the anterior and lateral portals were closed with #3-0 nylon. I then dressed the lateral wound with Dermabond, Steri-Strips, Xeroform, 4x4s, ABDs, and Medipore tape. The patient was placed in an UltraSling, an Iceman was applied, and he was taken to PACU in stable condition.
Excision of vaginal cuff granuloma
Does anyone know of a code for this? Everything I find leads to the unlisted 58999 and I have no idea how I would be able to get this precerted.
Any feedback is appreciated!
Thanks,
Denise
Orif greater tuberosity fracture with repair of rotator cuff
Can I bill the rotator cuff repair with the ORIF of the greater tuberosity fracture? I checked the NCCI edits 23630 and 23410 have a 1 indicator. According to the NCCI edits I don’t think I should but maybe some of you have some advice.
Thanks so much!
Laparoscopic Rotator Cuff Repair with Xenograft
Here are some excerpts from the operative documentation:
PROCEDURE:
Arthroscopic rotator cuff repair (29827).
Biceps tenodesis (29828).
Use of Xenograft porcine patch for rotator cuff approximation. (29999 ?) (HCPCS ?)
*Biceps Tenodesis
— biceps tendon was released
— biceps tendon was instilled in it and screw over it instilling 2 arms of the biceps into the tunnel with screw placement
— closed this area
*Rotator Cuff Repair
— identified the margins of the tear
— released as much of the tendon off the glenoid labrum and neck of the glenoid as possible
— released and free the anterior edge down to the coracoid
— a large crescentic tear
— placing 2 free stitches
— placed two 2.8 mm anchors
— repaired the native limbs of the rotator cuff
*Xenograft Placement
— created a triangular space
— parachuted the graft in
sewing it to the medial cuff tissue
Thank you in advance!
Shoulder augmentation rotator cuff repair
My doctor said he performed right shoulder augmentation rotator cuff repair with rotation medical allograft patch. This is a new one to me. I read somewhere that a 29827 would include the graft, but I’m not convinced. Or should I bill for a 29999 unlisted arthroscopic procedure and compare it to 29888 or 29889 even though these are augmentation to ligaments. Please help!
rotator cuff revision help!
who injured her right shoulder, had a primary right shoulder rotator
cuff repair arthroscopic assisted over 8 months ago back in April 2017,
however, re-injured her shoulder and also had continued to smoke when
she was counseled regarding smoking cessation. Followup MRI revealed a
propagation and retear of her rotator cuff tear. It was explained to
the patient the options and alternatives. Revision surgery was
indicated. The nature of procedure was discussed with the patient, which
would be an open revision rotator cuff repair with an augmentation. The
patient was explained the importance of smoking cessation, however, the
patient continues to smoke, although she shows me that she will quit
smoking. She was explained the risks and potential complications
include, but not limited to death, infection, blood clot, fracture,
neurovascular injury, pain, stiffness, scarring, bleeding, inability to
repair, retear, reaction to the graft, failure of repair, poor outcome,
deltoid insufficiency. The patient signed informed consent.
PROCEDURE IN DETAIL: The patient was taken to the OR. Right shoulder
was identified as the correct operative extremity by the patient. This
site was signed by the surgeon. 2 g of IV Ancef given preoperatively
within 1 hour of incision. The patient received a right interscalene
block in the holding area by Anesthesiology. The patient was placed
supine on the OR table. After adequate general anesthesia obtained, the
patient’s right shoulder was examined under anesthesia, had full range
of motion. No evidence of any instability. The patient was placed in a
semi-beach chair position with a spider attached. All bony prominences
were well padded. Right shoulder was then prepped and draped in a
standard sterile surgical fashion. Time-out performed indicating an
open revision right rotator cuff repair with augmentation as a correct
operative procedure. Using a standard open approach to the rotator cuff
repair starting at the just lateral to the coracoid in line with
Langer’s line extending to the lateral aspect of the acromion at the mid
point between the anterior and posterior acromion, this site was
preinjected with local anesthetic. Incision was then made with the
scalpel. Thick flaps were then raised. The deltoid was then split
starting at the anterior acromion extending distally, not more distally
than 5 cm from the acromion. This was tagged with a #5 Ethibond.
Retractors were then placed. Good hemostasis obtained with the Bovie
cautery. At this time, the rotator cuff tear was identified. There was
no evidence of any biceps tendon. The rotator cuff tear appeared to
involve just the supraspinatus tendon and had a V-shaped tear and it was
nonretracted, which already of the tendon remained attached to the
greater tuberosity. All suture anchors remained in place. The sutures
were then removed, however, the suture anchor was left in place, given
that these were imbedded in bone and not prominent and would be
technically difficult to remove without significant bone loss. The
greater tuberosity was then prepared with a rongeur and preparing a bony
trough from the articular margin of the humeral head to the greater
tuberosity. At this time, a side-to-side repair was performed, given it
was a V-shaped tear and a release was performed to the coracohumeral
ligament. The rotator interval was also intact. At this time, the side-
to-side repair was done to the supraspinatus tendon with #2 FiberWire
sutures in a figure-of-eight fashion from the level of the glenoid
laterally to the greater tuberosity. At this time, a 2.8 Q-Fix was
placed at the articular margin and then these sutures were passed in a
simple fashion to the anterior and posterior leaf and again to the
anterior and posterior leaf. Another 2.8 Q-Fix suture anchor was placed
at the lateral aspect of the footprint of the greater tuberosity and
then these were passed in a horizontal mattress-type fashion, one in the
anterior leaf and then one in the posterior leaf. At this time, a
matrix HD RTI Biologics graft was then trimmed. The rotator cuff tear
appeared to be about 2 cm in width, which made a medium size tear.
Therefore, the sutures left from the anchors were then passed through
the graft in a similar type fashion and then the sutures were then tied.
The Q-Fix anchor in the more lateral aspect of the greater tuberosity.
Sutures were then tied to themselves and then an another Q-Fix anchor
was placed at the lateral aspect of the greater tuberosity distal to the
insertion of the rotator cuff insertion and then these were passed in a
simple fashion in the anterior and posterior aspect of the graft and
then these sutures were then tied to the more lateral footprint 2.8 Q-
Fix anchors. The sutures were then cut. The medial Q-Fix anchor
sutures were also cut. Secure repair was performed. The shoulder was
examined and had no evidence of any impingement. The previous
acromioplasty had already been performed. There was no active bleeding.
A previous bursectomy was also performed. Therefore, only a minimal
open bursectomy needed to be performed. There were minimal adhesions in
the subdeltoid region. These were also released. The axillary nerve
was protected with the suture and then at this time, the incision was
copiously irrigated. The deltoid was then repaired to the acromion with
#2 FiberWire sutures in a figure-of-eight fashion and the deltoid split
was closed with #2 FiberWire sutures in a figure-of-eight fashion. A
secure repair of the deltoid was performed to the acromion. The
incision was then closed with 2-0 Vicryl suture in inverted fashion and
the incision was closed with 3-0 Monocryl sutures in a subcuticular type
fashion. Steri-Strips was then applied and a sterile dressing was
applied. Right upper extremity placed in UltraSling. The patient
tolerated the procedure well and was taken to recovery room in good and
stable condition.
arthroscopic SAD, mini open rotator cuff repair
Can you tell me where I might find references on this?
thanks so much for any insight!