MS Shoulder 2 - AAPC

Documentation Dissection

Pre-op Diagnosis: Rotator cuff tear, left

Post-op Diagnosis: Rotator cuff tear, left biceps tendinitis |1|

Procedure(s) (LRB): OPEN ROTATOR CUFF RECONSTRUCTION (Left)

Procedure: Left open rotator cuff repair and acromioplasty with biceps tenodesis |2|

Indication: chronic shoulder pain and a torn rotator cuff confirmed by MRI. The tear involved the supraspinatus, the infraspinatus, as well as the subscapularis muscles |3|

Narrative description:

After successful induction of general Anesthesia the patient was positioned on the operating table in the beach chair position. The shoulder was sterilely prepped and draped in the usual manner. The cuff was approached through a 5 cm in length parasagittal incision |4| positioned at the lateral edge of the acromion. Dissection was carried down until the anterior raphe of the deltoid could be seen and the anterior raphe was split longitudinally from the acromioclavicular joint to a point about 5 cm distal to the acromion. The deltoid was retracted exposing the torn cuff.

An acromioplasty was done |5| and the distal and lateral edge of the acromion resected to create a type one acromial shape. The cuff was then inspected. The rotator cuff was torn from approximately the equator of the humeral head posteriorly all the way around the greater tuberosity to the bicipital groove and then the subscapularis was also torn off the lesser tuberosity down to approximately the equator of the humeral head |6|.

The biceps tendon remained within the intertubercular groove but was thickened, erythematous, and markedly frayed on its undersurface such that it was less than 50% intact |7|. At this point it was elected to perform a biceps tenodesis |8| along with repairing the rotator cuff tendons. The biceps tendon was cut at the level of its insertion onto the superior labrum. The tuberosities as well as the bicipital groove were curetted down to bleeding bone.

The cuff was mobilized until it could be pulled over to the tuberosity. The tissue quality was quite good. The cuff was then attached to the tuberosity using 4 mitek fastin suture anchors and a mason -alien suture pattern |9|. One of the anchors was placed in the bicipital groove and used to firmly attach the biceps tendon into its bed and the biceps was also sutured to the supraspinatus and infraspinatus side to side to further augment its fixation |10|.

The repair resulted in the cuff being firmly approximated to the tuberosity. After this was accomplished the shoulder was brought through a range of motion and the cuff remained attached without excessive tension through the range of motion including with the arm adducted against the chest wall. The wound was copiously irrigated. The deltoid was re approximated to the acromion using non absorbable suture through bone holes.

The |11| skin edges were re approximated using 2 0 vicryl and 3 0 prolene. The wound was infiltrated with 0.5% marcaine with epinephrine for post op pain control.

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|1| The post-op diagnosis is used for coding.

|2| Indicates procedures performed.

|3| The description of the tear identifies a complete tear. The American Academy of Orthopedic Surgeons (AAOS) describes a complete tear as when the tear splits the soft tissue into two pieces and in some cases tendons tear off where they attach to the head of the humerus. This information is important in ICD-10-CM code selection.

|4| This confirms an open procedure rather than arthroscopically. This is necessary information for determining the appropriate CPT code.

|5| This is removal of a portion of the acromion in order to create space in the joint.

|6| This is confirmation of torn rotator cuff and identifies a complete tear.

|7| This is confirmation for biceps tendonitis.

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|8| Decision is made to repair the biceps tendon.

|10| Biceps tenodesis completed.

|9| Reconstruction of the rotator cuff

|11| Describes wound closure

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What are the CPT? and ICD-10-CM codes reported?

CPT? Codes: 23420-LT, 23430-51-LT

ICD-10-CM Codes: M75.122, M75.22

Rationale:

CPT: Two procedures are documented: an open left rotator cuff reconstruction with acromioplasty and biceps tenodesis. In the CPT Index go to Rotator Cuff/Repair. You're directed to the code range 23410-23420. Code 23410 is used to repair a rupture musculotendinous cuff for an acute condition and 23412 is used for chronic. The is not a repair of a ruptured musculotendinous cuff; this is reconstruction of a complete avulsion of the rotator cuff. Documentation indicates: The rotator cuff was torn from approximately the equator of the humeral head posteriorly all the way around the greater tuberosity to the bicipital groove and then the subscapularis was also torn off the lesser tuberosity down to approximately the equator of the humeral head. The appropriate CPT code is 23420, which includes acromioplasty. HCPCS Level II modifier LT is appended to indicate the left shoulder.

For the second procedure locate Biceps Tendon/Tenodesis in the CPT Index. You are directed to 23430 and 29828. Code 29828 describes an arthroscopic biceps tenodesis and isn't the method described in the operative report. Code 23430 is the correct code. Modifier 51 is appended to indicate multiple procedures and HCPCS Level II modifier LT is used to indicate left side.

ICD-10-CM: In the ICD-10-CM Alphabetic Index locate Tear/rotator/complete and you're directed to M75.12-. The Tabular List identifies M75.12 as a complete rotator cuff tear or rupture not specified as traumatic. This code requires a 6th character for laterality. M75.122 is the correct code for a complete rotator cuff tear or rupture of left shoulder, not specified as traumatic.

For the second diagnosis, use the ICD-10-CM Alphabetic Index to locate Tendinitis/bicipital. This directs you to M75.2-. The Tabular List identifies M75.2 as Bicipital tendinitis. A 5th character is required for laterality. M75.22 is the correct code for bicipital tendinitis, left shoulder.

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