Certificate of Attendance
Advanced Clinic: Shoulder Surgery CPT Coding
July 8, 2004
______NAME
Lolita M. Jones, RHIA, CCS Presenter
The American Health Information Management Association (AHIMA) has approved this program for two (2) continuing education clock hours in the External Forces content area.
Retain this certificate as evidence of participation. Advanced Clinic Skin Grafts
Advanced Clinic: AdvancedAdvancedSkin Graft Clinic: Clinic: ShoulderSkin Graft Surgery
Author: Presenter: LolitaLolita M. M. Jones, Jones, RHIA,RHIA, CCS CCS Presenter: LolitaLolita M. M.Jones Jones Consulting Consulting Services Services Lolita M. Jones, RHIA, CCS 19211921 Taylor Taylor AvenueAvenue LolitaFortFort M.Washington, Washington, Jones Consulting MD MD Services 20744 20744 1921 Taylor Avenue (V) 301-292-8027 Fort Washington,(V) 301-292-8027 MD 20744 (FAX) 301-292-8244 (FAX)(V) 301-292-8027 301-292-8244 Coding Training: www.hcprofessor.com Coding Training:(FAX) 301-292-8244 www.hcprofessor.com E-mail: [email protected] CodingE-mail: Training: [email protected] www.hcprofessor.com E-mail: [email protected]
All CPT CodesDistributed 2002Distributed American by HCPro,Medical by Association* HCPro, Inc. Inc. Lolita M. Jones Consulting Services 1 Advanced Clinic Shoulder Surgery
Table of Contents
Disclaimer 3
About Lolita M. Jones Consulting Services 4
Objective 9
I. Shoulder Surgery 10
A. Arthroscopic Heat Application 10
B. Arthroscopic Shoulder Decompression of Subacromial Space with Partial Acromioplasty 10
C. Injection for Shoulder Arthrography 11
D. Arthroscopic Rotator Cuff Repair 11
E. Partial Acromionectomy 11
Coding Resource: Shoulder Surgery-Arthroscopy vs. Open 12
F. Postoperative Pain Management 13
II. Case Studies 15
III. Answer Key 56
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Disclaimer Advanced Clinic: Shoulder Surgery is designed to provide accurate and authoritative information in regard to the subject covered. Every reasonable effort has been made to ensure the accuracy of the information within these pages. However, the ultimate responsibility lies with the user.
Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express or implied, that this compilation is error-free or that the use of this publication will prevent differences of opinion or disputes with Medicare or other third- party payers, and will bear no responsibility or liability for the results or consequences of its use.
Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted coding system owned and maintained by the American Medical Association.
Please contact Lolita M. Jones, RHIA, CCS at: (V) 301-292-8027 (Fax) 301-292-8244 Coding Training: www.hcprofessor.com E-mail: [email protected]
©2004 Lolita M. Jones Consulting Services
All five-digit number Physician’s Current Procedural Terminology, Fourth Edition (CPT) codes, service description, instructions and/or guidelines are 2003 American Medical Association. All rights reserved.
All rights reserved. The author grants permission for photocopying for limited personal use or internal use of the original purchaser. This consent does not extend to other kinds of copying, such as for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale.
• SHOULDER
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About Lolita M. Jones Consulting Services HOSPITAL TRAINING PROGRAMS Coding Training: www.EzMedEd.com (V) 301-292-8027 (FAX) 301-292-8244 E-mail: [email protected]
BIOGRAPHY:
Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital outpatient and ambulatory surgery center coding, billing, reimbursement, and operations. Ms. Jones recently launched her web-based coding program at www.EZMedEd.com. She has over 15 years of experience in publishing, training, and auditing for the hospital outpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones has earned both the Registered Health Information Administrator and Certified Coding Specialist credentials from the American Health Information Management Association (AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she has developed six (6) specialty manuals for freestanding ambulatory surgery centers (ASCs) as well as comprehensive manuals for the following ambulatory payment classification (APC) training programs:
Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for (Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement Specialists, Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital staff responsible for outpatient coding including emergency room, ancillary department and hospital-based clinic staff. The contents include general guidelines, steps for coding, and official CPT guidelines for surgical procedures that are commonly performed in the hospital outpatient setting. Exercises based on actual ambulatory surgery operative reports will be used to strengthen the attendees’ understanding of the guidelines presented.
APC Institute: Impact on Emergency Services: This 3 hour program is designed for Emergency Department: Directors, Managers, Supervisors, and Nurses; Registration Staff, Health Information Managers, Coding Specialists, and Cast Room Technicians. The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits, APCs for Emergency Department Services, Modifiers –25 and –27, Emergency Screening without Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound Closure, and Documentation Guidelines.
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APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program is designed for Compliance Department Staff (Corporate Officers, Directors, Managers, Analysts, Auditors); Health Information Management Staff (Directors, Coding Managers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators, Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors, Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsible for facility component outpatient coding in: Registration, Hospital-Based Clinics, Ancillary Departments, and the Emergency Department. The contents include: Brief Overview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: site- of-service billing, reason for visits, discontinued surgery, medical visits, “limited follow- up services,” colorectal cancer screening, observation stay without recovery, critical care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB- 92 claims data, and higher level APC groups.
APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed for nursing, utilization management, case management, and other health care professionals responsible for health records documentation. The contents include ambulatory payment classification (APC)-related clinical documentation requirements and management tips for the following sites of service: Emergency Room, Observation Beds/Unit, Ambulatory Surgery, Hospital-Based Outpatient Departments/Clinics, Pain Management Clinic, Series/Recurring Services, Partial Hospitalization Program, Cast Room, Ancillary Testing Areas, and Utilization Management.
APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed for all technical, clinical and managerial staff responsible for facility component outpatient coding that will directly impact ambulatory payment classification (APC) payments. The contents include: Ambulatory Surgery Reimbursement under APCs, APC Data Reporting Requirements, Medicare Hospital Outpatient Edits, Outpatient Billing Procedures and Guidelines, Ambulatory Claims Rejection Monitors, Peer Review Ambulatory Surgery Review, Coding System Reviews, How to Use ICD-9-CM, How to Use CPT, and CPT Coding Guidelines By Body System (Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).
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Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for coding, reimbursement, compliance, billing, database management, ancillary, and clinic staff responsible for modifier programming, reporting, billing, and auditing. The contents include: Modifier Reporting Requirements, Official Medicare Guidelines, Recommended Hospital Front-End Modifier Edits, Electronic/On-Line UB-92 Reporting of Modifiers, Coding and Billing Aborted/Discontinued Procedures, ICD-9-CM vs. Medicare Coding Guidelines, Unsuccessful vs. Aborted/Discontinued Procedures, Documentation of Reduced/Discontinued Procedures, Testing Potential Coders, Software Encoder Modifier Edits, Interventional Radiology Procedures, Information System Upgrades, Data Quality Review, Radiology Modifier Reporting Issues, Ancillary Department Modifier Reporting for Hospitals, and Exercises/Case Studies.
APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is designed for hospital executives, directors, chargemaster coordinators, coding/reimbursement staff, and information system/database managers who will implement ambulatory payment classifications (APCs). The contents include: General Overview of APCs, APC Data Reporting Requirements, APC Policy Issues, Developing a Plan of Action, Conducting Hospital-Wide APC Education, and Assessing Current Outpatient Operations for: Overall Hospital, Management Information Systems, Business Office/Patient Accounts, Health Information Management, Ancillary Departments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-Owned Satellite Facilities, Hospital-Based Physician Coding and Billing, and Utilization Management.
APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed for Chief Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster Coordinators, Database Managers, Software Vendor Product Managers, Coding Managers, Reimbursement Specialists, Director of Patient Accounts/Business Office, Outpatient Billing Supervisor/Coordinator, Outpatient Billing Specialists. The contents include: Durable Medical Equipment and Prosthetics, Pre-operative Registration, Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims Preparation, Claims Payment, Tracking and Reviewing Medicare Billing Guidelines.
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Lolita M. Jones Consulting Services FREESTANDING AMBUALTORY SURGERY CENTER TRAINING PROGRAMS
ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for Freestanding ambulatory surgery center (ASC) Managers (Business, Nurse, Reimbursement), Directors, Administrators, Coding Supervisors, Coding Specialists, and Billers. The contents include: Current Freestanding ASC Structure, Proposed Freestanding ASC Structure, Medicare Coding Requirements, Medicare Billing Requirements, Coding Ambulatory Surgery, How To Use CPT When Coding Ambulatory Surgery, and CPT Coding Guidelines By Body System (Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).
ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: tissue expander, pedicle flap, pressure ulcer, skin grafts, nail avulsion and excision, scar revision, burn treatment, lesion excisions, wound repair, adjacent tissue transfer/rearrangement, breast surgery, free flaps with microvascular anastomosis.
ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: cataracts. intraocular lens, keratoplasty, trabeculectomy, strabismus surgery, punctum plugs, tarsorrhaphy, trichiasis correction, retinal detachment repair, vitrectomy.
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ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: hernia repair, nasogastric intubation, percutaneous gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage, dental procedures, covered and noncovered colorectal cancer screening, gastrointestinal endoscopy, esophageal dilation.
ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: ganglion cyst, joint injections, decompression fasciotomy, treatment of fractures/dislocations, skeletal anatomy of the hand and foot, surgical knee arthroscopy, bunionectomy, toe-to-hand transfer with microvascular anastomosis.
ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: retrograde pyelogram, ureter vs. urethra, urethral dilation, ureteral stent, urethral stent, Burch Procedure, vesicourethropexy/urethropexy, urodynamics, chemotherapy.
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OBJECTIVE: This program will first provide a detailed review of the shoulder surgery CPT coding guidelines to assist the participants in their understanding of the numerous techniques that are performed. “Real life” operative report case studies will also be presented for many of the shoulder surgery techniques that are discussed.
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I. Shoulder Surgery
A. Arthroscopic Shoulder Heat Application
Assign unlisted arthroscopy CPT code 29999 to report the use of heat to shrink the capsule in the shoulder performed through an arthroscope. (Source: CPT Assistant newsletter, August 1998, page 11.)
B. Arthroscopic Shoulder Decompression of Subacromial Space with Partial Acromioplasty
The arthroscopic procedure involves exposing the subacromial space, bursectomy, debridement, detaching the coracoacromial ligament and removing the undersurface of the acromion. When subacromial decompression is performed, a flat undersurface of the acromion and 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 be inclusive components of code 29826. [Source: May 2001 CPT Assistant newsletter, AMA]
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C. Injection for Shoulder Arthrography
To report an MRI of the shoulder with intra-articular contrast (MR arthrography of the shoulder), it is appropriate to report 23350 for the shoulder joint injection. Report 76003 if fluoroscopic guidance was used to guide needle placement into the joint, and 73222 for the MRI shoulder with contrast.
Coding Tip: There is a correct coding initiative (CCI) edit in place as a comprehensive code pair edit for 23350 and 76003, since fluoroscopic-guided imaging is considered included in the radiographic arthrography code (73040). Therefore, modifier –59, Distinct procedure, should be appended to 76003 to designate the fluoroscopic guidance as a distinct and separate procedure when radiographic arthrography is not performed. (July 2001 CPT Assistant newsletter, AMA).
D. Arthroscopic Rotator Cuff Repair
Rotator cuff injuries are strains or tears of one or more rotator muscles or tendons, the most common site being the supraspinatous muscle. Acute tears result from trauma, such as falls on an outstretched hand or injuries from football throwing, baseball or softball pitching. Racquetball serving or manipulation of a frozen shoulder. Chronic tears originate from over-use or constant stress. Assign CPT code 23410 or 23412 for repairs involving one or two tendons or major muscles of the rotator cuff. Assign CPT code 23420 for a repair of 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 newsletter, AMA.
Clinical Tip: The major muscles of the rotator cuff: supraspinatus, infraspinatus and teres minor.
. Partial Acromionectomy
23410 [Repair of musculotendinous cuff (e.g. rotator cuff); acute] includes the work involved in performing a partial acromionectomy (23130). Therefore, it would not be appropriate to report 23130 separately. (Source: August 2001 CPT Assistant, AMA).
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Coding Resource:
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F. Postoperative Pain Management
Source – 2001 Complimentary Issue CPT Assistant newsletter, AMA:
• CPT reporting of peripheral nerve/plexus nerve catheter placement is based on the :
* exclusion of other anesthesia service(s); * performance of concomitant operative service(s) by same physician; and * target nerve involved.
• If the catheter is placed primarily for anesthesia administration during an operative session, then the appropriate anesthesia services code(s) should be reported.
• If placement is performed for the purpose of post-operative pain management by the same physician at the time of another operative service (e.g., total shoulder reconstruction), then the appropriate 64400-64450 series code should be reported with the modifier –51 appended (if modifier –51 is acceptable by the third-party payer).
• The appropriate nerve block code (64400-64450) should also be reported when the catheter is placed by a physician, other than the physician performing anesthesia or surgical services. For example, for placement of a lumbar plexus catheter, code 64449 should be reported. Similarly, a sciatic nerve catheter insertion would be reported with the appropriate code.
• Currently, there is no specific CPT code for “daily” management of the peripheral or plexus nerve catheter. It is not appropriate to report anesthesia code 01996 as this is specific to epidural catheters (NOTE: anesthesia CPT codes are frequently non- reportable by hospitals to most third-party payers).
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October 2001 CPT Assistant newsletter, AMA:
• When general anesthesia is administered and pain management injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter, injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure is immaterial.
• If, on the other hand, the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone. In a combined epidural/general anesthetic, the block cannot be reported separately.
Examples:
[NOTE: Many third-party payers do not accept CPT anesthesia codes from hospitals.]
• A femoral nerve block placed to provide post-operative analgesia for an anterior cruciate ligament repair or a total knee replacement would be reported separately from the surgical anesthesia.
• A patient undergoing a thoracotomy might receive an epidural injection of a local anesthetic and/or narcotic (62318) for postoperative pain control in addition to the general anesthetic, which is administered through an endotracheal tube (00540). In this case, the epidural is not the surgical anesthetic and it would be reported separately, as an independent procedure.
• Shoulder surgery could be performed under an interscalene brachial plexus block that would also provide postoperative analgesia. This would be reported using the anesthetic code (e.g., 01620). If the block were intended primarily to alleviate postsurgical pain, and a general anesthetic was administered for the shoulder procedure, the block would be separately reportable.
• A brachial plexus block might also provide both the anesthesia and the postoperative pain control for an open reduction of a wrist fracture. Only the anesthesia code would be reported.
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II. Case Studies
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Case Study # 1. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS: Adhesive capsulitis, large rotator cuff tear on the right shoulder.
POSTOPERATIVE DIAGNOSIS: Adhesive capsulitis, large rotator cuff tear on the right shoulder.
OPERATION: Manipulation under anesthesia of the right shoulder and injection of steroids into the right glenohumeral joint.
INDICATIONS: This is a 74-year-old female who has had persistent pain, loss of mobility in the shoulder. She has 9 degrees at forward flexion and abduction both passively and actively. Internal rotation is also limited to the level of L5 and she has 30 degrees of external rotation. She has a known rotator cuff tear but she also has significant adhesive capsulitis. I will try to immobilize the shoulder first and if we need good mobility and strength and no other treatments really necessary for the rotator cuff tear; however, she has persistent pain and she regains mobility then eliminating to fix the rotator cuff.
PROCEDURE/FINDINGS The patient was placed in the supine position on the operating table. After adequate general anesthesia was given, we gently manipulated obtaining full mobility back to the shoulder and then placed 20 cc of 0.25% Marcaine with epinephrine and 2 cc of Solu-Medrol. She was discharged to the recovery room in satisfactory condition. She would start in a physiotherapy program and the CPM machine.
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Case Study # 2. Please assign the CPT code(s)-modifiers for this case: ______.
PREOPERATIVE DIAGNOSIS: Right acromioclavicular arthritis.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Excision, right distal clavicle.
ANESTHESIA: General.
PROCEDURE: The patient was taken to the operating room and identified. General endotracheal anesthesia was induced. The patient received prophylactic Ancef and was placed in the beachchair position. The right shoulder was prepped and draped in the usual sterile manner. The skin was incised over the AC joint. Bleeders were coagulated with the Bovie. The joint was subperiosteally exposed. The micro-saw was used to remove 1 cm of the distal clavicle. The end of the clavicle was arthritis. The wound was irrigated. Hemostasis was reassessed. The wound was closed with 2-0 Vicryl and staples. After closure, the area was injected with 0.5% Marcaine without epinephrine. The patient was taken to the recovery room in stable condition.
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Case Study # 3. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. Right rotator cuff rupture. 2. Right acromioclavicular joint disease.
POSTOPERATIVE DIAGNOSIS: 1. Right rotator cuff rupture. 2. Right acromioclavicular joint disease.
OPERATION PERFORMED: 1. Right rotator cuff reconstruction using curve TAC instrumentation. 2. Open Mumford procedure.
ANESTHESIA: General.
INDICATIONS: The patient is a 69-year-old white male who has a right rotator cuff tear. He has failed nonoperative treatment. He also has been noted to have right AC joint disease, has weakness, pain and discomfort in the shoulder. He is brought today for definitive treatment. He is aware of possible risks and benefits.
PROCEDURE: The patient underwent general anesthesia without event. He was sterilely prepped and draped in the usual fashion. He was placed in a semirecumbent barber chair position.
An incision was made over the anterolateral aspect of the shoulder extending over the AC joint. The subcutaneous was identified and incised. Dissection was carried down to the level of the superior AC ligament. Subperiosteal dissection was performed. Distal clavicle was identified. There was noted to be a large spur and severe degenerative changes over the clavicle. Distal clavicle was then excised first using a saw and then a rasp to smooth out the area. The wound was copiously irrigated out.
Attention was then placed to the lateral acromion. A subperiosteal dissection was performed off the lateral acromion and deltoid split was performed. Bursa was excised. There was noted to be a very complex rotator cuff tear. Complete avulsion of supraspinatus, infraspinatus and teres minor off the greater tuberosity. Biceps tendon was noted to be intact. There was noted to be a second tear which was separate and a longitudinal tear between the interval between the supraspinatus and the infraspinatus as well. This was a hypertrophic type tear. There was calcification in the edges of the tendon in that area. The calcific deposits were then excised and the longitudinal tear was repaired in a side-to-side fashion between the supraspinatus and infraspinatus.
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Case Study # 3 - continued
After completion of this, there was a longitudinal tear in the infraspinatus as well which was appreciated. There were some calcium deposits in that as well and these were excised as well. Using a #2 Ethibond suture, retention sutures were then placed over the cuff and it was delivered laterally. A Cobb elevator was then used to free up the adhesions and bring the cuff laterally, both deep and superficial to the cuff. A rongeur was taken and a trough was made laterally. The wound was copiously irrigated out. Hemostasis was obtained with electrocautery. Using a curved TAC instrumentation after adequate mobilization of the cuff was completed, the cuff was delivered in the three drill holes which had been placed laterally with a #2 Ethibond suture utilized. The cuff was then oversewn after having been tied with the arm at the side with good coaptation into the trough itself. The cuff was then oversewn using the Ethibond as well as 0 Vicryl. After completion of this, the wound was copiously irrigated out. The joint was copiously irrigated as well. Prior to closure of the joint, an anterior-inferior acromioplasty was done at that point as well. A rasp was utilized prior to closure of the cuff to smooth out the inferior aspect of the acromion. Hemostasis was obtained using electrocautery. The superior AC ligament was then closed using 0 vicryl figure-of-eight. The deltoid split was repaired using 0 Vicryl figure-of-eight suture. Subcutaneous was closed using 3-0 Vicryl and skin was closed using staples. A sterile compressive dressing was placed. The patient tolerated the procedure well and left the operating room in stable condition.
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Case Study # 4. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Complete rotator cuff tear of right shoulder.
POSTOPERATIVE DIAGNOSIS: Complete rotator cuff tear of right shoulder.
OPERATION PERFORMED: Repair of complete rotator cuff tear right shoulder with acromioplasty.
ANESTHESIA: General.
PROCEDURE: The patient was placed supine on the Operating Room table at which time he was put to sleep under general anesthesia. Following this, a bump was then placed beneath the left scapular area. The shoulder was then prepped with Betadine Solution for a full five minute prep and draped in a sterile fashion. A saber type incision was made over the superior aspect of the shoulder and carried down through skin and subcutaneous tissue to the underlying tip of the acromion. The attachments of the deltoid muscle were released and subacromial space identified. Here there is noted to be evidence of a complete avulsion of the rotator cuff with approximately 1 cm of retraction. This measured approximately 1.5 cm in width. In order to better visualize as well as to decompress an oblique osteotomy cut was made across the tip of the acromion. This was smoothed with a rasp. Next, the tear was mobilized and the bed prepared. Two bone anchors were used to reattach the rotator cuff. Once done there was good stability at the repair site. The area was then thoroughly irrigated with antibiotic solution following which two drill holes were placed in the remaining tip of the acromion. #1 PDS sutures were then placed through these and the deltoid muscle was reattached. This was oversewn with another #1 PDS suture. Subcutaneous tissues were closed with #3-0 Vicryl. Skin was closed with #5-0 Vicryl subcuticular suture. The wound was then dressed in a sterile fashion and a sling and swathe applied. The patient was then returned to the Recovery Room in satisfactory condition.
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Case Study # 5. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Adhesive capsulitis, left shoulder.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Left shoulder arthroscopy with manipulation, lysis of adhesions and pain capsular release.
INDICATIONS: The patient is a 58 year old with recalcitrant adhesive capsulitis. He failed nonoperative management. He failed initial manipulation. He elected to proceed with the above procedure and risks and benefits were discussed with him and I answered all his questions, consents were signed and placed on the chart.
OPERATIVE TECHNIQUE: The patient was taken to the Operating Room, was placed in the supine position and given general anesthesia per Anesthesia protocol. He was given 1 gram of IV Kefzol and brought up in the beach chair position. Pressure points were well padded. The arm was then manipulated and brought to a near forward flexion. External rotation was to about 45 degrees. There was extensive release with the manipulation. The posterior portal was established. After prepping and draping in the usual sterile fashion, the posterior portal was established, the anterior portal was established. A 4.5 shaver was used to debride the synovitis. Underwater electrocautery was used for capsular release anteriorly. Once the capsular release was complete all down to 6 o’clock from the manipulation, the remainder that needed to be released was superiorly from 3 to 1 o’clock.
This was completed and the 4.5 shaver was used to debride the remainder capsular tissue for this release. Once this was complete, the portals were switched and the scope was placed in the anterior portal and a working portal was then used posteriorly. Posterior capsular release was performed. The arm was, then again, manipulated and the release was completed from about 5 o’clock up to a 1 o’clock position posteriorly. The arm was then manipulated and external rotation was achieved to about 65 degrees. Once this was complete, the joint was lavaged. The scope was removed. A pain pump was introduced in the subacromial space. The wounds were closed with 4-0 nylon. Sterile dressing was applied. The patient was awakened and taken to the Recovery Room in stable condition.
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Case Study # 6. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS: Chronic rotator cuff impingement syndrome and acromioclavicular arthrosis, right shoulder.
POSTOPERATIVE DIAGNOSIS: Chronic rotator cuff impingement syndrome and acromioclavicular arthrosis, right shoulder.
OPERATION: Arthroscopy right shoulder with arthroscopic subacromial decompression and open Mumford distal claviculectomy.
ANESTHESIA: General.
INDICATIONS: The patient is a 47-year-old security guard with long history of progressive right shoulder pain, primarily at the acromioclavicular joint. He has responded well but only temporarily to the previous acromioclavicular and subacromial cortisone injections. Because of chronic symptoms, which have failed conservative management, the patient was taken to the operating room at this time to undergo arthroscopic subacromial decompression and Mumford distal claviculectomy.
PROCEDURE/FINDINGS: After induction of awaken nasal intubation and general anesthesia, the patient was placed in the upright sitting position in the beachchair attachment to the operating room table. The right upper extremity was prepped and draped free in the usual fashion. Bony landmarks were outlined with a marking pen and a standard posterior portal was made after instilling the glenohumeral joint and subacromial space with 0.25% Marcaine with epinephrine. The glenohumeral joint was inspected. The glenohumeral surfaces demonstrate some minimal grade 1 chrondromalacia. There was some minimal fraying of the undersurface of the rotator cuff but no tear. Biceps and subcapularis tendons were normal. The anterior labrum was normal. The arthroscope was removed from the glenohumeral joint and reinserted into the subacromial space through the posterior portal and a second portal was made laterally along the edge of the acromion. Using a combination of a full radius shave, Arthrocare Cautery wand and a acromionizer bur, a subacromial decompression was performed removing soft tissue from the undersurface of the acromion, removing several millimeters of bone and detachment of the coracoacromial ligament from the anterior edge of the acromion. Because of the patient’s large size of over 300 pounds, and somewhat difficult visualization, it was elected to perform an open Mumford distal claviculectomy.
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Case Study # 6 - continued
Arthroscopic instruments were removed and incision was made overlying the Case acromioclavicular joint and carried down to subperiosteally expose the distal clavicle. Approximately 1.5 cm of distal clavicle was excised with a sagittal saw and the end of the bone was rasped smooth. Periosteal and fascial tissues were closed with multiple #1 Vicryl interrupted sutures and the wound was then irrigated and infiltrated with 0.25% Marcaine with epinephrine for postoperative pain relief. Portals and wounds were closed in routine fashion.
An indwelling, Marcaine pump catheter was placed at the distal claviculectomy site for postoperative pain relief. Sterile dressings and a sling were applied after reversal of anesthesia.
The patient was transported to the recovery room in stable condition. There were no apparent intraoperative complications.
All CPT Codes 2003 American Medical Association 23 Advanced Clinic Shoulder Surgery
Case Study # 7. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
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.
ANESHESIA: General and block.
INDICATION FOR PROCEDURE: The patient is a 51-year-old male with reclacitrant shoulder pain and a frozen shoulder. He had failed rehabilitative and injection treatments and requested operative intervention.
FINDINGS AT OPERATION: Preoperative motion was 90 degrees of flexion and 30 degrees of external and internal rotation. There was significant subacromial bursitis with very thickened coracoacromial ligament and a subacromial spur. The intra-articular 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 the above noted limitation of motion was found. An interscalene block was placed for postop pain control and the patient was placed in the beach chair position. The right shoulder was manipulated with palpable and audible crepitace into 150 degrees of elevation, external rotation was to 80 with the opposite shoulder being 90, and internal rotation was equivalent at 70. Adduction and abduction were equivalent. The shoulder was prepped and draped in a 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. 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 deltotrapezial 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.
All CPT Codes 2003 American Medical Association 24 Advanced Clinic Shoulder Surgery
Case Study # 7 - continued
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 acomioplasty 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.
All CPT Codes 2003 American Medical Association 25 Advanced Clinic Shoulder Surgery
Case Study # 8. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. Left shoulder rotator cuff tear with subacromial impingement.
POSTOPERATIVE DIAGNOSIS: 1. Left shoulder rotator cuff tendonitis/synovitis.
OPERATION: Left shoulder arthroscopy, glenohumeral debridement, limited. Subacromial decompression.
ANESTHESIA: General.
FINDINGS: The patient had an MRI which reportedly demonstrated a rotator cuff tear. There was no tear noted either on the bursal surface or on the articular surface. There was evidence of an impingement-type lesion on the greater tuberosity; however, the rotator cuff insertion appeared to be intact. The rotator cuff was inspected both on the articular and bursal surfaces. There was significant hyperemia throughout the rotator cuff, and there was some questionable synovitis throughout the joint. A tissue sample was sent for a pathologic evaluation, as the patient did have psoriasis. The patient previously did undergo rheumatologic workup, which was reportedly negative. The patient had a subacromial spur.
PROCEDURE: The patient was brought to the operating room and placed on a table in a supine position. General anesthesia was induced. The left shoulder was prepped and draped in the usual sterile fashion. A posterior portal was created, through which the osteoscope was introduced. The above-noted findings were appreciated. An anterior portal was then created with a Wissinger rod. Through this anterior portal the shaver was introduced, and limited glenohumeral debridement was performed. Next, attention was directed to the subacromial space, and a standard lateral portal was created through which the cautery device and arthroscopic shaver were used to perform a bursectomy.
Upon completion of the bursectomy, the borders of the acromion were defined. A burr was used to perform an acromioplasty. The arthroscope was then introduced into the lateral portal, and the burr was placed posteriorly. The burr was used to plane the acromion. The AC joint was then visualized by using cautery and shaver to remove the inferior capsule. There was a spur on the undersurface of the distal clavicle, and this was coplaned. The rotator cuff was then inspected, and was found to be intact along its bursal surface.
All CPT Codes 2003 American Medical Association 26 Advanced Clinic Shoulder Surgery
Case Study # 8 - continued
Wounds were irrigated copiously. Instruments were removed. 3.0 nylon sutures were used to close the skin. A sterile dressing was applied. The patient was brought to the recovery room in stable condition, having tolerated the procedure well.
All CPT Codes 2003 American Medical Association 27 Advanced Clinic Shoulder Surgery
Case Study # 8 - continued
PATHOLOGY REPORT
Age/Sex: 55/M Received: 04/24/02-1322 Spec Type: SURGICAL P
PREOPERATIVE DIAGNOSIS: LEFT SHOULDER IMPINGEMENT
OPERATION PERFORMED:
DATE: 04/24/02 PROCEDURE: LEFT-ARTHROSCOPY SHOULDER W/DECOMP ACROMIOPLASTY; OPEN ROT REPAIR
TISSUE REMOVED
A. SYNOVIAL BIOPSY (LT SHOULDER)
GROSS DESCRIPTION
RECEIVED LABELED SYNOVIAL BIOPSY. THE SPECIMEN CONSISTS OF A NODULE OF TAN GRAYISH TISSUE MEASURING 0.3 CM IN GREATEST DIMENSIONS. ALL BLOCKED.
PATH PROCEDURES
PROCEDURES: PATH DSM, A1 BLK
FINAL DIAGNOSIS
SYNOVIUM, LEFT SHOULDER, BIOPSY: DENSE FIBROUS TISSUE SHOWING SCANT CHRONIC INFLAMMATION. SYNOVIAL MEMBRANE IS NOT UNEQUIVOCALLY IDENTIFIED.
All CPT Codes 2003 American Medical Association 28 Advanced Clinic Shoulder Surgery
Case Study # 9. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS: 1. Rule out partial tear, rotator cuff, right shoulder. 2. Chronic impingement syndrome.
POSSTOPERATIVE DIAGNOSIS: 1. Partial tear, rotator cuff, supraspinatus tendon, 20 x 20 mm (30 to 40% torn), right shoulder. 2. Chronic impingement syndrome with large subacromial spur and marked fraying of the coracoacromial ligament.
OPERATION: 1. Arthroscopic subacromial decompression (arthroscopic acromioplasty) with coracoacromial ligament release using electrocautery. 2. Extensive arthroscopic debridement of undersurface, partial tear, rotator cuff and supraspinatus tendon (20 x 20 mm, approximately 30% torn), right shoulder.
ANESTHESIA:
INDICATIONS: The patient is a 55-year-old male who has been followed since April 2002 for severe adhesive capsulitis of the right shoulder. The adhesive capsulitis has significantly improved with conservative treatment including injection, medications and physical therapy.
X-rays obtained on October 5, 2002 revealed a normal glenohumeral joint with a type II acromion. Despite a good passive range of motion, the patient continued to have debilitating night pain, pain with over-activity and weakness of the rotator cuff.
An MRI was performed on December 19, 2001 and revealed rotator cuff tendinitis.
The patient has persisted with debilitating pain. The patient and his family understand the serious nature of the proposed operative procedure. They understand the inherent risks involved.
All CPT Codes 2003 American Medical Association 29 Advanced Clinic Shoulder Surgery
Case Study # 9 - continued
PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position. Following the induction of general anesthesia, the patient was rotated to the left lateral decubitus position with the right side up. The right shoulder was then prepped and draped in the usual sterile fashion.
Standard portals were used for the arthroscopic examination of the right shoulder. Examination of the glenohumeral joint revealed normal articular surfaces. The anterior and posterior glenoid and labra were intact; the middle and inferior glenohumeral ligaments were intact. There was mild fraying of the biceps tendon.
The underside of the rotator cuff revealed a large underside partial tear measuring 20 x 20 mm, estimated to be 30 to 40% torn. This area was extensively debrided using the full-radius resector. The arthroscope was then placed anteriorly and posteriorly for further evaluation of the rotator cuff and for more extensive debridement.
The arthroscope was then placed into the subacromial space using the standard anterior, posterior and lateral portals. Examination of the superior side of the rotator cuff revealed marked fraying of the supraspinatus tendon. There was no complete tear identified.
The underside of the acromion revealed a large subacromial spur with marked fraying of the coracoacromial ligament. This was transected with the use of electrocautery. The underside of the acromion was then debrided using the Dyonics acromioplasty blade and the Dyonics clavicularis blade; in this manner, 5 to 8 mm of bone were resected.
The arthroscope was then placed laterally and the shaver was inserted posteriorly to further flatten the anterior hook of the acromion. The acromioclavicular joint was visualized arthroscopically. Soft tissue was resected with the use of electrocautery.
Due to the absence of preoperative acromioclavicular joint pain, a distal clavicle excision was not carried out. The superior side of the rotator cuff was extensively debrided and the partial tear was estimated to be approximately 30 to 40%, involving only the supraspinatus tendon.
The wounds were copiously irrigated throughout the procedure. Then 0.25% Marcaine with epinephrine was instilled into the arthroscopic portals and 20 cc were placed into the joint. A dry bulky compressive dressing was applied.
The patient tolerated the procedure well and was transferred to the recovery room in a good condition.
All CPT Codes 2003 American Medical Association 30 Advanced Clinic Shoulder Surgery
Case Study # 10. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Right rotator cuff tear.
POSTOPERATIVE DIAGNOSIS: 1. Right partial thickness rotator cuff tear. 2. Subacromial impingement. 3. Acromioclavicular joint arthritis.
OPERATION: 1. Right shoulder arthroscopy. 2. Subacromial decompression. 3. Arthroscopic Mumford (distal clavicle) resection. 4. Limited glenohumeral debridement.
ANESTHESIA: General.
OPERATIVE FINDINGS: The patient had an MRI which was reported as showing a full thickness rotator cuff tear. She had evidence of undersurface fraying. However, there was no evidence of a full thickness tear. A Prolene suture was placed at the articular surface at the articular margin of the rotator cuff tendon where it appeared to have a partial thickness tear. When this bursal surface was probed there was no evidence of a full thickness tear. The spur was removed as was the distal clavicle.
PROCEDURE: The patient was brought to the operating room, placed on the operating room table in the supine position. Right shoulder was prepped and draped in the usual sterile fashion. Right shoulder was then entered through a standard posterior portal. The above noted arthroscopic findings were appreciated. A Wissinger rod was used to create an anterior portal for the inside-out technique. There was some fraying of the biceps tendon at its anchor. However, there was no instability. The biceps anchor origin was debrided. There was evidence of an undersurface fraying of the rotator cuff. This was debrided as well in a limited fashion. Next a Prolene suture was passed through a spinal needle in this area where the tendon appeared attenuated. It was grasped through the anterior portal and left out at the skin as a tag suture and marking suture for later inspection from the bursal surface. Instruments were then removed from the glenohumeral joint. The arthroscope was placed into the subacromial space. A standard lateral portal was created. Through this lateral portal a cautery device was used as was a shaver to perform a bursectomy. We defined the borders of the acromion. A bone spur was found on the undersurface of the acromion. This was resected using the acromioblaster. Next the distal clavicle was exposed. The distal clavicle was then resected as well.
All CPT Codes 2003 American Medical Association 31 Advanced Clinic Shoulder Surgery
Case Study # 10 - continued
The arthroscope was placed into the lateral portal. Acromioblaster was used to plane the acromion. The distal clavicle was also resected through this posterior portal. Next attention was directed directly to the anterior AC joint, and the camera was placed into the AC joint, and the completion of the distal clavicle resection was performed by creating a posterior portal just behind the AC joint, the port of Neviaser. The portal was then placed. Distal clavicle was resected.
The superior capsule was left intact. Wounds were then irrigated. Instruments were removed. 3-0 nylon was used to close the skin. Sterile dressing was applied. The patient was placed in a shoulder immobilizer and brought to the recovery room in stable condition.
All CPT Codes 2003 American Medical Association 32 Advanced Clinic Shoulder Surgery
Case Study # 11. Please assign the CPT code(s)-modifiers for this case: ______.
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. 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.
All CPT Codes 2003 American Medical Association 33 Advanced Clinic Shoulder Surgery
Case Study # 11 - continued
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.
All CPT Codes 2003 American Medical Association 34 Advanced Clinic Shoulder Surgery
Case Study # 12. Please assign the CPT code(s)-modifiers for this case: ______.
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.
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.
All CPT Codes 2003 American Medical Association 35 Advanced Clinic Shoulder Surgery
Case Study # 12 - continued
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.
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.
All CPT Codes 2003 American Medical Association 36 Advanced Clinic Shoulder Surgery
Case Study # 13. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE RECORD
PREOPERATIVE DIAGNOSIS: Left shoulder acromioclavicular joint arthroscopy with possible rotator cuff tear.
POSTOPERATIVE DIAGNOSIS: Superior labrum anterior and posterior (SLAP) lesion, left shoulder with acromioclavicular joint arthritis and impingement.
OPERATION: 1. Arthroscopy of left shoulder with repair of superior labrum anterior and posterior (SLAP) lesion. 2. Arthroscopic Mumford procedure and subacromial decompression.
ANESTHESIA: General.
INDICATIONS: This is a 64-year-old male who has been followed for some time with shoulder pain of the left side. He has failed conservative treatment and presents for definitive treatment.
MRI and symptoms are consistent with AC joint arthrosis as well as possible rotator cuff tear.
PROCEDURE: The patient was taken to the operating room and placed in the supine position. After general anesthesia was obtained, he was placed in the beach-chair position with all bony prominences carefully padded. The left shoulder was prepped and draped in the usual sterile fashion.
First, a posterior portal was made, and a diagnostic arthroscopy was performed. Immediately noted was a significant SLAP lesion on the anterior aspect of the labrum. The rotator cuff was inspected and was noted to be completely intact. There was some mild synovitis around the SLAP lesion as well.
Next, an anterior portal was made. The labrum was probed. Most of the labrum was well attached to the anterior lip of the glenoid.
Next, ArthroCare wand was used to repair the SLAP lesion as well as debride it. With this completed then, the synovectomy was completed as well. The biceps tendon was intact as were all other ligament and structures.
All CPT Codes 2003 American Medical Association 37 Advanced Clinic Shoulder Surgery
Case Study # 13 - continued
Next, attention was paid to the subacromial space. In the subacromial space, a subacromial bursectomy was performed with the ArthroCare wand. AC joint arthrosis was noted. This was debrided also with the ArthroCare system. The distal clavicle was excised with a large bur. Also, the opposing acromion was smoothed down with the bur as well completing our subacromial decompression.
The area was copiously irrigated. The wounds were gently approximated with 4-0 undyed Vicryl. The whole area was infiltrated with 0.5% Marcaine with epinephrine and 0.75% Marcaine plain for postoperative anesthesia. Bulky dressing was placed and held with tape. ABD was placed under the armpit, and the arm was placed in a regular sling.
Estimated blood loss was minimal. The IV fluid replaced: Less than 3000 cc of crystalloid. Drains and packs: None. Complications: None.
The patient tolerated the procedure well and was taken to the recovery room in a good postoperative condition.
All CPT Codes 2003 American Medical Association 38 Advanced Clinic Shoulder Surgery
Case Study # 14. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Bilateral shoulder impingement syndrome and rotator cuff tears with a SLAP lesion of right shoulder.
POSTOPERATIVE DIAGNOSIS: Bilateral shoulder impingement syndrome and rotator cuff tears with a SLAP lesion of right shoulder.
OPERATIVE PROCEDURE: Arthroscopic subacromial decompression and distal clavicle planing, both shoulders, with debridement of SLAP lesion of right shoulder followed by mini-open repair of rotator cuff tears of both shoulders.
INDICATIONS: Mr. Scott is a 55-year-old man, who has persistent and worsening bilateral shoulder pain, right shoulder worse than left. Because of the persistent problems with his shoulders, he is indicated for arthroscopic inspection of the rotator cuff repair. The patient desired to do both shoulders at same time.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, where a suitable general anesthetic was induced. He was initially positioned on his side, left shoulder up so that we could work on his left arm. His left arm was placed in the shoulder holder and the shoulder was prepped and draped in the usual sterile fashion. The arthroscope was instilled through a posterior portal and a shoulder inspection carried out revealing normal-appearing glenohumeral joint and biceps tendon with a rough irregular under surface of the rotator cuff consistent with the rotator cuff tear. The instruments were then placed in the subacromial space and a thorough subacromial decompression was carried out. Rotatory bur, Mitek debrider and the synovial dissector were used to debride the subacromial space. The clavicle was coplaned.
Following this thorough decompression and observation of the rotator cuff tear, a mini- open incision was made laterally and carried down through the deltoid. The deltoid was split at the midline raphe and the anterior of the shoulder was inspected. Two sutures of #2 Panacryl were placed through the edge of the cuff and the SCOI fashion holding the edge of the cuff securely. One Bio-Absorbable Arthrex suture anchor was placed at the articular margin and two sutures were placed through the rotator cuff more proximally. Two sutures through the edge of the cuff were tied through bone holes using the Concept instrumentation. The four sutures were then tied, allowing for a two- layer repair of the rotator cuff. The repair was quite secure. Once the sutures had been tied, the deltoid was re-approximated with 0 Panacryl and subcutaneous tissues with 2-0 Monocryl and the skin with running subcuticular Prolene. Steri-Strips and sterile dressings were placed. The patient turned with the left shoulder down, right shoulder up, and the same procedure performed on the right. The only difference being that the
All CPT Codes 2003 American Medical Association 39 Advanced Clinic Shoulder Surgery
Case Study # 14 - continued
superior border of the labrum and the biceps tendon had a rough, irregular area consistent with a nondisplaced SLAP lesion. This was debrided with a synovial dissector. The rotator cuff was repaired in the same fashion with the same suture techniques.
The repair was quite secure. A little more of the deltoid was detached at the acromion on the right, than the left. One #2 Panacryl suture was placed through the acromion and through the deltoid to secure the deltoid back to the acromion. Following the procedure, the patient was placed in two slings. He was turned, awakened, and taken to recovery in satisfactory condition.
All CPT Codes 2003 American Medical Association 40 Advanced Clinic Shoulder Surgery
Case Study # 15. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. Right shoulder multidirectional instability. 2. Right rotator cuff impingement. 3. Right acromioclavicular joint arthrosis.
POSTOPERATIVE DIAGNOSIS: 1. Right shoulder multidirectional instability. 2. Right rotator cuff impingement. 3. Right acromioclavicular joint arthrosis.
OPERATION: 1. Right shoulder arthroscopy. 2. Arthroscopic subacromial decompression. 3. Arthroscopic distal clavicle resection. 4. Arthroscopic thermal capsulorrhaphy of the shoulder.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
CONDITION: To the PACU stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the main operating room suite where she was placed supine on the operating room table and underwent administration of a general anesthetic. After which the right upper extremity and shoulder were prepped and draped under sterile conditions. Marcaine 0.25% with epinephrine was used to infiltrate the proposed incision sites and the anterolateral superimposed sites. The shoulder was distended with 40 cc of saline through the posterior shoulder portal and the posterior shoulder portal was made. The arthroscope was placed into the glenohumeral articulation where there was noted to be a redundant axillary pouch involving the inferior glenohumeral ligament. All ligaments were intact. The biceps were normal. The humeral head was found to have normal articular cartilage, as was the same on the glenoid. An anterior portal was made and a thermal capsulorrhaphy was performed with the use of the CapSure ArthroCare wand, so as to reduce and eliminate the patient’s complaints of neurologic issues radiating into the hand, particularly given that the EMG was negative. The arthroscope was then placed into the subacromial space, where subacromial decompression was performed with the use of the ArthroCare wand, the 4.0 shaver, and the 5.0 burr. Thereafter the distal clavicle resection was performed, removing approximately 9 to 10 mm of the distal clavicle.
The incisions were irrigated and thereafter closed with 3-0 Prolene sutures. The shoulder was thereafter injected with 20 cc of 0.5% Marcaine and 5 mg of Duramorph. It was dressed with Xeroform, 4 by 4 gauze pads, fluff, ABD, basic tape, and a basic sling. The patient was taken to the PACU in stable condition.
All CPT Codes 2003 American Medical Association 41 Advanced Clinic Shoulder Surgery
Case Study # 15 - continued
SURGICAL PATHOLOGY REPORT
DOB: 8/9/1958 (Age: 45) SEX: F
Specimen(s) Received A. right distal clavicle
Final Diagnosis Right Distal Clavicle, showing mild nonspecific reactive changes of the osteochondrous tissue.
The bone marrow shows normocellular marrow for age with all three hematopoietic cell lines with progressive maturation.
Clinical History (Not Provided)
Gross Description The specimen is labeled “right distal clavicle”.
The specimen is submitted in formalin and consists of a roughly dome-shaped portion of bone measuring 2.0 x 1.5 x 1.0 cm. The dome portion of the bone shows attached fibrous brown tan tissue. The opposite surface is a cut-surface showing trabeculated spongy bone. The specimen is serially sectioned and submitted in its entirety after decalcification. Two sections/one cassette Entire specimen submitted.
All CPT Codes 2003 American Medical Association 42 Advanced Clinic Shoulder Surgery
Case Study # 16. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE NOTE
ANESTHESIA: General, with interscalene block augmentation, right shoulder.
PREOPERATIVE DIAGNOSIS: Torn rotator cuff.
POSTOPERATIVE DIAGNOSIS: 1. Massive tear rotator cuff. 2. AC joint arthritis. 3. Dislocated biceps tendon anteriorly.
OPERATIVE PROCEDURES: 1. Open repair of massive and chronic rotator cuff tear, with acromioplasty and CA ligament resection. 2. Open Mumford procedure (AC joint resection). 3. Biceps tenodesis.
PROCEDURE: Under a good general anesthetic, augmented by interscalene block, the patient’s right shoulder is examined. The patient has no abnormalities on inspection. The patient is put through a massive range of motion. With the arm abducted to 90 degrees, he can externally rotate to about 70, internal rotation is about 50 and forward elevation is to about 160-170. There is no evidence of instability.
At this point, the patient is placed in the beach chair position and the sandbag placed underneath the operative scapula. The right shoulder and neck are prepped and draped in the usual fashion for right shoulder surgery. A modified anterolateral approach is made to the shoulder. A 2-inch incision starts under the palpable AC joint and extends distally and laterally for a couple of inches. The incision is taken through skin and subcutaneous tissues, down to the deltoid. The deltoid is split along the raphe, separating the anterior and middle deltoid fibers. The deltoid is subperiosteally dissected from the anterolateral border of the acromion. The CA ligament is identified and resected. The humeral head is depressed with a Cloverleaf retractor and an anterior inferior acromioplasty is performed.
The undersurface of the acromion is smoothed out with a rasp. We are very happy with our decompression. The AC joint is identified. There is inferior spurring and arthritic changes in the AC joint, so a Mumford is performed. An oblique osteotomy is performed, removing the distal 1 cm of the clavicle, maintaining the superior AC ligaments. Thorough irrigation of this area is performed. Again, the undersurface is
All CPT Codes 2003 American Medical Association 43 Advanced Clinic Shoulder Surgery
Case Study # 16 - continued
rasped to a smooth surface. We are very happy with our decompression of the subacromial arch area.
Attention is now paid to the cuff. There is an obvious massive tear involving the supraspinatus, infraspinatus and teres minor. There is also a rotator interval split. The biceps tendon is dislocated anteriorly. The hypertrophic bursa is resected. The biceps tendon is relocated into its bicipital groove and tenodesed with #1 Ethibond. The free edges of the rotator cuff are identified and 0 Vicryl is used for stay sutures. The cuff is mobilized. We are very happy with the mobilization. A trough is made into the greater tuberosity. The cuff is then repaired tendon-to-bone into the trough with #1 Ethibond.
We are very happy with our repair. The rotator interval is then closed with #1 Ethibond as well. There is no undue tension with the cuff at the neutral position. We are happy with our repair. Thorough irrigation is performed. Hemostasis is achieved where necessary and closure started. The deltoid is reattached to the anterior acromion with #1 Ethibond. The deltoid split is closed with #1 Ethibond. The subcutaneous tissues are closed with 2-0 Vicryl and the skin with staples. The wounds are cleaned and dried. A sterile compression dressing is applied. The patient is put into an abductor pillow. There were no intraoperative complications. The patient tolerated the procedure well and went to the recovery room in good condition.
All CPT Codes 2003 American Medical Association 44 Advanced Clinic Shoulder Surgery
Case Study # 17. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: RECURRENT INSTABILITY AND BANKART LESION LEFT SHOULDER.
POSTOPERATIVE DIAGNOSIS: SAME.
PROCEDURE PERFORMED: ARTHROSCPIC LEFT BANKART REPAIR AND ELECTRICAL THERMAL SHRINKAGE OF THE CAPSULE.
ANESTHESIA: Intrascalene block.
INDICATION FOR SURGERY: This is a 52-year-old gentleman with recurrent dislocation to his left shoulder; elected for operative intervention.
OPERATIVE PROCEDURE: The patient was properly identified, brought to the Operating Room; had intrascalene block gently induced. The left upper extremity was prepped and draped in the usual sterile fashion and placed in modified beach-chair position, all bony prominences being padded and he was secured to the table. The left upper extremity was prepped and draped in the usual sterile fashion. Posterior portal was performed two fingerbreadths below the posterior scapula spine, two fingerbreadths medially. Blunt for the camera sheath was introduced into the glenohumeral space and the joint was inflated and the camera was applied. There was anterior tearing of the labrum from the 12 o’clock to the 6 o’clock position with some chondromalacia, Grade II, to the glenoid. There was a Hill-Sacks lesion noted. The subscapularis and the surface of the rotator cuff biceps tendon was intact. At which point under 18 gauge spinal needle guidance, anterior portal was performed and a disposable cannula was placed through this. The area was shaved to abrade the anterior glenoid because bleeding points could help the labrum heal in. A guide-wire was drilled for the Surtak system, drilled over which. This was removed then and the Surtak system, drilled over which. This was removed then an the Surtak anchor was then deployed. This was done x three. A second anterior portal had to be deployed however it had to be made to adequately deploy an appropriate anchor. Upon the three anchors being deployed, probing showed excellent stability to the labrum. At which point the Tak-S Oratec blade was then placed into the joint and used to electrical thermally shrink; the collagen fibers decreased the volume in the joint. This was then removed as well as the rest of the instrumentation. The joint was copiously irrigated with irrigant solution and suctioned dry. The portals were closed with interrupted 4-0 nylon; 10 mg of Duramorph was injected intra articularly. Sterile dressing with Xeroform, 4 x 4, Combine and shoulder immobilizer was applied.
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Case Study # 17 - continued
COMPLICATIONS: None.
DRAINS: None.
The patient returned to the recovery room in stable condition.
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Case Study # 17 - continued
SURGICAL PATHOLOGY REPORT
DOB: 9/16/1938 (Age: 62) SEX: M
Pathologic Diagnosis:
DEBRIDED TISSUE LT SHOULDER: Fragments of Synovium.
Nature of Specimen:
DEBRIDED TISSUE LT SHOULDER
Gross Description:
The specimen is received in formalin and consists of two cloth filters containing approximately 4 cc in aggregate of pale gray and yellow tissue. Representative sections are submitted. One cassette.
All CPT Codes 2003 American Medical Association 47 Advanced Clinic Shoulder Surgery
Case Study # 18. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left recurrent anterior shoulder instability.
POSTOPERATIVE DIAGNOSIS: Left recurrent anterior shoulder instability.
OPERATION: Left shoulder Bankart capsulorrhaphy, open.
INDICATIONS: The patient is a 24-year-old ruby player who presents with recurrent anterior shoulder instability. The patient had a fairly new history of symptoms and rehabilitation without complete resolution of his instability symptoms.
PROCEDURE/FINDINGS: The patient was brought to the main operating room and placed supine on the operating room table. After satisfactory endotracheal intubation general anesthetic, the patient was placed in the modified beach-chair position with the left arm on an arm board. Her shoulder was examined under anesthesia, and it was able to be dislocated anteriorly. The left shoulder was prepped and draped in a sterile fashion. Subcutaneous tissue was infiltrated with 10 cc of 0.25% Marcaine with epinephrine.
Approximately an 8 cm incision was made from the coracoid process down the axillary crease. This was carried down through soft tissue down to the deltopectoral fascia. Medial and lateral flaps were elevated. The deltopectoral intervals were identified and sharply and bluntly developed. The cephalic vein was retracted medially. The conjoined tendon was then mobilized laterally and retracted medially. Soft tissues were then held with an Innovasive self-retaining retractor. This gave us excellent visualization of the subscapularis muscle. In the midsubstance of the subscapularis from medial to lateral, the subscapularis was split with electrocautery down to the capsule. Superior and inferior flaps of the subscapularis was immobilized and retracted with a Gelpi retractor. A dural retractor was placed medially, and a medial to lateral capsulotomy was made. A Fukuda retractor was placed holding the humeral head laterally with good visualization of the glenoid rim. The patient had evidence of an old Bankart lesion and had some abrasions and thinning of the anterior glenoid and appeared to have an old Bankart lesion that at least tried to heal. He was mobilized from 6 o’clock to 9 o’clock, and two Mitek anchors were placed in the glenoid rim. These were then used to anchor the capsule to the glenoid rim. The shoulder was then irrigated out. A #1 Mersilene and OS-1 needle were then used to do an imbrication stitch bringing the inferior flap over the superior flap. These were tied in the shoulder in neutral position. This reduced the capsular redundancy.
All CPT Codes 2003 American Medical Association 48 Advanced Clinic Shoulder Surgery
Case Study # 18 - continued
At this time the shoulder was irrigated again. The subscapularis muscle was reapproximated with #1 Vicryl suture. Self-retaining retractors were taken out. The wounds were observed for hemostasis. Hemostasis was obtained. The subcutaneous tissue was reapproximated with 3-0 Vicryl suture, and the skin closed in a running subcuticular 3-0 Prolene. Wound edges were infiltrated with an additional 20 cc of 0.25% Marcaine with epinephrine. Steri-Strips were used to reinforce this skin closure. The wounds were dressed with Xeroform, plain dressing sponges, ABD pad, and foam tape. The patient was placed in a shoulder immobilizer, extubated and brought to the recovery room in stable condition.
All CPT Codes 2003 American Medical Association 49 Advanced Clinic Shoulder Surgery
Case Study # 19. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Recurrent anterior shoulder dislocation left.
POSTOPERATIVE DIAGNOSIS: Recurrent anterior shoulder dislocation left.
OPERATION: Open capsular shift reconstruction left shoulder.
ANESTHESIA: General anesthesia.
ESTIMATED BLOOD LOSS: Less than 100 cc.
DRAINS: None.
INDICATIONS FOR SURGERY: This is a 24-year-old gentleman who is status post open Bankart reconstruction left shoulder. He had done excellent until he had a work-related injury June 26, 2000. His shoulder slipped out of joint and he has had a couple of other episodes of dislocations of the shoulder which required reduction in the emergency room, so he was admitted for elective reconstruction.
His exam under general anesthesia revealed significant anterior instability, some subluxation posteriorly. Negative sulcus sign.
PROCEDURE/FINDINGS: The skin was prepped and draped in a sterile fashion. The original surgical incision over the anterior left shoulder was excised. The deltopectoral interval was developed. The cephalic vein was not encountered, I would probably say it had been previously ligated. There was significant scar tissue adjacent to the conjoined tendon. It was carefully separated. The underlying subscapularis muscle was identified. The subscapularis muscle was transected 1 cm medial to its insertion on the humerus and then carefully dissected free of the capsule and retracted so that the capsule could be identified. The previously placed capsular stitches were still in place and identified. The capsule was split longitudinally to the glenoid at the junction of the proximal two-thirds and lower third of the capsule and a Bankart lesion encountered. The labrum was excised additionally inferiorly and the glenoid rim and neck were roughened with a rasp. Mitek SuperAnchors were placed, one at about 5:30 and the other at approximately 8:30 on the glenoid, and then these anchors and attached stitches were used to reattach the inferior capsule and labrum to the glenoid, pulling it superiorly and then using previously placed #2 Ethibond sutures, the inferior capsule was pulled and reefed superiorly underneath the superior capsule. Stitches were placed but not tied and then with the arm in the neutral position and some slight abduction, the stitches were tied. This gave excellent stability to the shoulder. The superior capsule was then pulled inferiorly further reinforcing the repair.
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Case Study # 19 - continued
At this point then soft tissues were injected with quarter-percent Marcaine with epinephrine and the subscapularis muscle was reattached to the humerus with #2 Ethibond and some #1 Vicryl suture. Subcutaneous tissue was closed with 2-0 Vicryl and the skin with skin clips. Sling-and-swathe were applied and the patient returned to the recovery room in satisfactory condition.
All CPT Codes 2003 American Medical Association 51 Advanced Clinic Shoulder Surgery
Case Study # 20. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left posterior shoulder instability.
POSTOPERATIVE DIAGNOSIS: Left posterior shoulder instability.
OPERATION: Left posterior capsulorrhaphy.
INDICATIONS: The patient is 20-years-old and right hand dominant who sustained a traumatic posterior shoulder dislocation while doing martial arts training earlier this year. The patient has had an extensive period of rest, modified activity and physical therapy, and continues to have functional posterior instability.
PROCEDURE/FINDINGS: The patient was brought to the main operating room and placed supine on the operating table on a beanbag. After satisfactory endotracheal intubation with general anesthetic, the patient is placed in the lateral decubitus position with the left side up. The patient was secured in this position. All bony prominences padded. The patient was then prepped and draped in a sterile fashion and placed on a _____ stand in front of the table holding his arm in neutral rotation. Approximately an 8 cm incision was made posteriorly from approximately 2 cm medial to the posterior corner of the acromion from the spine down to the axillary crease. This was secured down through the soft tissues, identifying the deltoid fascia. This was incised, in line with the skin incision. The deltoid muscles were then split over the posterior joint. These were retracted exposing the posterior rotator cuff. Incision between his infraspinatus and teres minor was developed and carried down through the posterior capsule. Once this was identified, Cobb elevator was used to lift the muscle and pin it off the posterior capsule. This gave us actually very nice visualization of the posterior capsule. This retraction was held with an innovative self-retaining retractor. The arm was then manipulated abduction and adduction and internal and external rotation to further delineate the margins of the posterior capsule. A transverse incision was then made. The capsule was very thin. Posterior labrum was inspected and there was no evidence of a posterior Bankart lesion. The shoulder drum was irrigated out. Then using a #1 Ethibond on an OS1, four imbrication stitches were placed posteriorly mobilizing inferior capsule superiorly and the superior capsule inferiorly. Then with the arm in neutral position and about 30 degrees abduction, wound was irrigated out. Self-retaining retractor was removed. Hemostasis was adequate. Superficial fascia with deltoid was closed with running #1 Vicryl suture, subcutaneous tissues were reapproximated with 3-0 Vicryl suture. The skin was closed with a running subcuticular 3-0 Prolene reinforced with Steri-Strips. Wound edges were infiltrated with 20 cc of 0.25% Marcaine with epinephrine.
All CPT Codes 2003 American Medical Association 52 Advanced Clinic Shoulder Surgery
Case Study # 20 - continued
The wound was dressed with plain dressing, sponges, ABD pads and foam tape. The patient was then placed in an ultra sling with an abduction pillow keeping the arm in 0 degrees of rotation. The patient was then placed supine, extubated and brought to the recovery room in stable condition.
All CPT Codes 2003 American Medical Association 53 Advanced Clinic Shoulder Surgery
Case Study # 21. Please assign the CPT code(s)-modifiers for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Tear of right supscapularis tendon and subluxation of long-head biceps tendon (per MRI).
POSTOPERATIVE DIAGNOSIS: Tear of right subscapularis tendon and sublimation of long-head biceps tendon (per MRI).
TITLE OF THE OPERATION: Arthrotomy, right shoulder, implantation of long-head biceps tendon in humeral head and reattachment of subscapularis tendon.
ANESTHESIA: General endotracheal.
OPERATIVE HISTORY: 58-year-old white male sustained injury to his right shoulder with clinical impression of subscapularis tear almost five weeks earlier. He failed to respond to therapy and symptomatic care. Hence MRI then obtained verifying the diagnosis and also showing some subluxation of the biceps tendon. Now brought for surgery.
OPERATIVE FINDINGS: Medial dislocation of the long-head biceps tendon, avulsion of the subscapularis from the lesser tuberosity with only a few strands of tendonous tissue remaining attached. The supraspinatus and infraspinatus appeared grossly intact. There was retraction of about 2-3 cm of the subscapularis tendon and adhesion to the underlying capsule. Articular surface that could be visualized was normal.
OPERATIVE PROCEDURE: Following administration of anesthesia, the patient in the beach-chair position, the right shoulder area was prepped and draped in the usual manner. Deltopectoral approach was made with skin incision starting at or just above the level of the coracoid process and extending about 3-1/2 - 4 inches distally. The deltopectoral grove was identified, cephalic vein retracted laterally, incision deepened lateral to the conjoined tendon exposing the capsular tissue of the shoulder joint. This was incised in the region of the rotator interval and the subscapularis tendon was identified, retracted medially. There was separation of the undersurface of the subscapularis and the capsule. Using scissor dissection, marking sutures were placed in the subscapularis and the biceps tendon was relocated but would readily dislocate and appeared there was no reasonable way to confine it to the groove without impingement. Therefore, the biceps was released at its attachment to the superior labrum. The portion of the bicipital groove was denuded using osteotome and, just above that, a 5.0 mm suture anchor, bioresorbable, was inserted with two #2 Mersilene sutures through the eye. These were utilized to secure the tendon in what appeared to be an
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Case Study # 21 - continued
appropriate amount of tension, and then the remaining proximal stump was curled over and sutured through that stump, plus the long-head tendon distal to the previous sutures and through the adjacent cuff tissue for re-enforcement. Then three #2 abraded Nylon sutures were woven through the subscapularis. Multiple holes were drilled in the lesser tuberosity and the sutures were pulled through the prepared drill-holes and were then tied which replace the subscapularis to the lesser tuberosity. The repair was tested by abducting and externally rotating the shoulder, although not taken to an extreme. The repair appeared very secure. Wound was irrigated with saline, closed routinely, sterile bandage and shoulder immobilizer applied. The patient tolerated the procedure well.
All CPT Codes 2003 American Medical Association 55 Advanced Clinic Shoulder Surgery
III. Answer Key
Case Study 1 23700-RT 20610
Case Study 2 23120-RT
Case Study 3 23120-RT 23420-RT
Case Study 4 23420-RT
Case Study 5 29825-LT
Case Study 6 29826-RT 23120-RT
Case Study 7 29826-RT 23120-RT 64415
Case Study 8 29826-LT 29822-59-LT
Case Study 9 29823-RT 29826-RT
All CPT Codes 2003 American Medical Association 56 Advanced Clinic Shoulder Surgery
Case Study 10 29826-RT 29824-RT 29822-59-RT
Case Study 11 29826-RT 29827-RT Per the American Academy of Orthopaedic Surgeons’ Global Service Data for Orthopaedic Surgery 2004 , code 29827 includes a partial synovectomy.
Case Study 12 29807-RT 29826-RT 29824-RT
Case Study 13 29807-LT 29824-LT 29826-LT 20610
Case Study 14 29826-50 23412-50 29807-RT
Case Study 15 29824-RT 29826-RT 29999-RT
Case Study 16 23420-RT 23430-59-RT 23120-RT
All CPT Codes 2003 American Medical Association 57 Advanced Clinic Shoulder Surgery
Case Study 17 29806-LT 29999
Case Study 18 23455-LT
Case Study 19 23455-LT
Case Study 20 23465-LT
Case Study 21 23450-RT 23440-RT
All CPT Codes 2003 American Medical Association 58