Sample Coded report for Shoulder Arthroscopy CPT code

PREOPERATIVE DIAGNOSIS: 1. Left shoulder Rotator cuff tear. 2. Subacromial bursitis.  3.  Subacromial impingement. 4.  Acromioclavicular arthritis.  5. Biceps tendon tear.

POSTOPERATIVE DIAGNOSIS: 1. Same

PROCEDURE: 1. Left shoulder arthroscopic rotator cuff repair.with soft tissue augmentation. 2. Subacromial decompression/acromioplasty. 3. Arthroscopic debridement of subacromial space and glenohumeral joint.  4.  Arthroscopic distal clavicle excision/Mumford procedure. 5. Mini-open subpectoral biceps tenodesis. 

ANESTHESIA GIVEN: General with interscalene block

PREOPERATIVE ANTIBIOTICS: Ancef 2 gm IV

ESTIMATED BLOOD LOSS: minimal

INDICATIONS FOR PROCEDURE: The patient has a history of shoulder pain that has been unresponsive to conservative measures.  I have recommended a shoulder arthroscopy with possible rotator cuff repair, subacromial decompression, distal clavicle excision, mini-open biceps tenodesis and any other indicated procedures. We have discussed the risks and benefits of the procedure including pain, bleeding, infection, damage to tendons vessels and nerves, need for further surgery, hardware pain, hardware failure, stiffness, arthritis, deep venous thrombosis, pulmonary embolus, scar, numbness around the scar.

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Sample Coded report for Rotator Cuff repair CPT code

PROCEDURE IN DETAIL: The correct extremity was marked preoperatively and the patient verbally confirmed the correct surgical site and procedure to be performed. The patient was brought to the operating room and laid in the lateral decubitus position. The operative upper extremity was placed in balanced suspension and prepped and draped in the usual sterile fashion. A posterior portal was created and the arthroscope was placed into the glenohumeral joint. An anterior portal was then created. The glenohumeral joint was evaluated thoroughly. The articular cartilage over the humeral head was normal. The articular cartilage of the glenoid was normal. The glenoid labrum was thoroughly probed and noted to have no evidence of detachment. The biceps tendon was noted to have extensive tearing.  A biceps tenotomy was performed for later tenodesis. The articular side of the rotator cuff was thoroughly evaluated. The supraspinatus tendon demonstrated a full thickness tear. The infraspinatus tendon demonstrated a full thickness tear.  The subscapularis demonstrated a normal insertion.

The scope was placed into the subacromial space and a lateral portal was created. The bursa was thoroughly debrided using an arthroscopic shaver and an ArthroCare wand. The CA ligament was identified and noted to have bursal sided scuffing consistent with subacromial impingement. An ArthroCare wand was used to identify the undersurface of the acromion. There was noted to be an anterior slope of the acromion causing subacromial impingement. An arthroscopic burr was used to perform an acromioplasty. The A-C joint was identified. There was a large inferior osteophyte at the A-C joint. The osteophyte was impinging upon the rotator cuff. An arthroscopic burr was used to perform a distal clavicle excision/Mumford procedure. The rotator cuff was evaluated on the bursal side and demonstrated a full thickness tear.  There was noted to be severe retraction medial to the glenoid.  

The tear was noted to be significantly atrophic.  Margin convergence sutures were then placed. The sutures were tied and the tails were cut.  The humeral head just lateral to the articular margin was thoroughly debrided of any soft tissue and lightly decorticated to allow for direct bone to tendon healing. An accessory lateral portal was created. Two suture anchors were placed just lateral to the articular margin of the humeral head. The suture arms were passed through the rotator cuff tissue in a simple fashion. Knots were tied using arthroscopic SMC knots.  The sutures were cut.

 Because of the poor quality of the rotator cuff tissue, a soft tissue augmentation patch was indicated. The appropriate-sized patch was selected. The patch was deployed through the lateral portal. Soft tissue staples were used to stabilize the patch medially. The inserter was then removed. Additional soft tissue staples were placed anteriorly and posterior. Bone staples were placed laterally. The patch was probed and noted to be stable.

A small 2.5 centimeter incision was created in the axilla. The incision was created just at the inferior border of the pectoralis major. After incision of the skin, blunt dissection with a fingertip was performed. The long head of the biceps was palpated. A Homan was placed over the lateral aspect of the proximal humerus and medially, an Army-Navy retractor was used. A 90° hemostat was introduced underneath the biceps tendon and the biceps tendon was pulled out of the joint and bicipital groove and out of the incision. Measurements were taken to ensure correct tension. A Q-fix suture anchor was placed in the bicipital groove. The sutures were then passed through the biceps tendon at the musculotendinous junction in a modified Kraków fashion. The biceps tendon was then reduced into the bicipital groove. Arthroscopic knots were tied. The suture was cut. The tendon was palpated and noted to be stable. This completed the biceps tenodesis.

The arthroscopic equipment was removed from the shoulder. The wounds were closed using a 3-0 nylon suture in a simple fashion. The axilla was closed in a subcuticular fashion.  The wounds were then dressed using 4 x 4 gauze, ABD pad and tape. The patient was placed in an abduction sling. The patient was brought to the recovery room in satisfactory condition.

ICD 10 code ; M75.122 Complete tear of left rotator cuff, unspecified whether traumatic

CPT codes:

29827   SURGICAL ARTHROSCOPY SHOULDER W/ROTATOR CUFF RPR; (-LT Left side of body)

23430  TENODESIS LONG TENDON BICEPS; (-LT Left side of body)

23929  UNLISTED PROCEDURE SHOULDER; (-LT Left side of body)

29824  SURGICAL ARTHROSCOPY SHOULDER DSTL CLAVICULC; (-LT Left side of body)

29826  SURGICAL ARTHROSCOPY SHO W/CORACOACRM LIGM RLS; (-LT Left side of body)