Sample Coded report for Shoulder Arthroplasty CPT code

Pre-op Diagnosis: Arthritis of left shoulder region [M19.012]

Left shoulder rotator cuff tear arthropathy and severe degenerative changes at the level of the glenohumeral joint with inferior humeral head osteophyte formation.

Post-op Diagnosis: Same as Pre-op

Procedure(s):  Left – LEFT REVERSE TOTAL SHOULDER ARTHROPLASTY

Anesthesia: General and interscalene regional nerve block.

Estimated Blood Loss: 200 mL

Specimens:  Standard arthroplasty specimens.

Implants: DJO reverse total shoulder arthroplasty   –     glenoid base plate with 30 mm screw length.  Circumferential screw x3-22 mm, 14 mm, 22 mm.  Glenoid head with retaining screw size 32 mm -4 mm.  Humeral stem, small shell, 6 mm x 108 mm.  Small socket polyethylene insert 32 mm neutral.

Complications: None

Technique:

70-year-old female with prior treatment for left hip osteoarthritis and trochanteric bursitis. She also has a history of left knee osteoarthritis and undergoes periodic injections.

She is status post left shoulder arthroscopy with rotator cuff debridement and repair (supraspinatus), proximal biceps tenodesis, lysis of adhesions, major synovial/intra-articular/labral debridement and chondroplasty, and a subacromial decompression performed February 18, 2022.

She is also status post left shoulder manipulation under anesthesia with glenohumeral injection under fluoroscopy performed July 8, She is now status post left shoulder closed manipulation under anesthesia with intra-articular injection under fluoroscopy May 26, 2023.

3 views of the left shoulder reveal moderate/severe degenerative changes at the level of the humeral joint with inferior humeral head osteophyte formation.

She continues to have weakness with rotator cuff testing as she does have a rotator cuff tear.

She fell in November and has had a significant increase in pain and limited motion in her left shoulder since the time of her injury.

A CT scan of the left shoulder was performed at doctor’s imaging on January 12, 2023, revealing severe glenohumeral osteoarthritis as well as acromioclavicular joint osteoarthritis. Her humeral head is slightly high riding.

We have discussed the risks and benefits of surgical intervention. These include pain, bleeding, infection, damage to tendons vessels and nerves, need for further surgery, hardware pain, hardware failure, postoperative stiffness, deep venous thrombosis, osteoarthritis. All questions were answered and informed consent was obtained. The patient was given post op pain medication (Norco, Celebrex, Gabapentin) and instructed on how to take them. The patient is aware of the risk of taking narcotic pain medication. The patient will be NWB in an ultra sling for the first 4 weeks. Orders were placed for PT/OT with Home Health to help with mobilization, gait training, home safety and assistance with ADLs. . Okay for pendulums only to shoulder the first 2 weeks and can then start gentle passive range of motion to the shoulder only with PT/OT. Elbow ROM can be performed as tolerated. At 4 weeks post op, the patient will be transitioned into outpatient PT.

DVT Prophylaxis with TED hose for one week and Aspirin 81 mg daily for 2 weeks.

The operative shoulder was marked and the patient was taken to the recovery room for an interscalene regional nerve block by the anesthesia staff. The patient was then taken to the operating room and placed supine on the operating room table. General anesthesia was induced. Examination under anesthesia revealed:

The patient was then placed in the beachchair position with well-padded prominences and extremities. The operative extremity was prepped and draped in the normal sterile fashion. A timeout was conducted to verify correct patient, correct site, and administration of preoperative antibiotics.

The procedure began with an incision that began just lateral to the coracoid at the level of the clavicle and just lateral to the interval in order to prevent a sulcus scar. A cephalic vein was visualized, retracted, and preserved. The deltopectoral interval was entered and the conjoined tendon was visualized. Subdeltoid adhesions were released bluntly and a release of tissue around the conjoined tendon was performed. The upper fibers of the pectoralis major tendon was released. The anterior humeral circumflex vessels were cauterized. The bicipital groove was palpated and visualized, localizing the long head of biceps tendon within the groove. Curved Mayo scissors were utilized in order to open around the bicipital groove and into the rotator interval between the supraspinatus and subscapularis tendon locations. The Mayo scissors were then placed deep into the glenohumeral joint and a deep release was performed. The long head of the biceps tendon was then tenodesed to the pectoralis major tendon with Ethibond suture.

Sequential external rotation of the upper extremity was then performed and capsular tissue was released anteriorly, providing satisfactory visualization of the humeral head.

With the humeral head fully delivered into the wound, I was able to use the bicipital groove as a guide to centralize implants.

A humeral head cut was made in a guided fashion.  There was severe degeneration of the humerus and the glenoid.

The glenoid was then visualized after a release of the posterior inferior capsule, superior capsule just above the long head biceps tendon stump on the glenoid, and anterior capsular release involving the medial middle glenohumeral ligament and inferior glenohumeral ligament. The axillary nerve was protected anteriorly and inferiorly. The biceps and labral tissue were both taken down, releasing all soft tissue.

The central aspect of the glenoid was then marked and reaming ensued.

A baseplate with screw was then placed with satisfactory fixation. Locking screws were then placed sequentially and circumferentially around the central baseplate screw. This provided rigid fixation.  Three separate screws were placed.

The gleno sphere was then placed with satisfactory positioning and stability.

Reaming/broaching then ensued for the humeral head to a size 6. This provided good stability and implants were placed. The shoulder was reduced and satisfactory stability and glide was noted. There was satisfactory range of motion in multiple planes.

Prior to the humeral implant being placed, Ethibond suture was passed through bony tunnels within the humeral canal in order to provide a suture anchor effect for the surrounding soft tissue. This was tied to surrounding soft tissue for further stability.

Thorough wound irrigation was performed throughout. A layered closure was performed with a combination of Vicryl and Monocryl suture. Steri-Strips and sterile dressings were applied. The patient was placed into an UltraSling. The patient was awakened and taken to PACU in stable condition.

My first assistant was present for the entirety of the case. My first assistant was vital to this case for maintenance of extremity position, passage of instrumentation, implant placement, and closure.

CPT and ICD -10 code:

23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER; (-LT Left side of body)

M19.012 – Primary osteoarthritis, left shoulder