THE CODING EDGE® ARCHIVES

Table of Contents

Coding Recommendations - Feature Article 02/15/99
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" patient report.

Hint: The following text is, as you would expect, very technical and "dense;" we suggest you print this page for easier use. Your Browser's "File, Print" command should achieve this with no problem. Should you have difficulties printing this -or any other- page, please let us know.

   


  
   

Preoperative Diagnosis: AC joint arthrosis and osteoarthritis, right shoulder

Postoperative Diagnosis: Same

Procedure: Arthroscopy with labral debridement and distal claviculectomy, right shoulder

Indications for Procedure: This patient has had painful limited range of motion in his right shoulder for over a year. Arthrogram shows no rotator cuff tears. He reports no other joint problems. He presents at this time for arthroscopy and repair as indicated.

Description of Procedure: The patient was taken to the Operating Room and prepped and draped in the usual sterile fashion. After adequate general ET anesthesia, the patient was positioned in the left lateral decubitus position and a posterior portal was made with a #11 blade. The scope was inserted and advanced through the shoulder joint up to the anterior aspect of the capsule. A Wessinger rod was used to slide through the cannula and out to the skin in front. A small skin incision was made at this point and the instrument cannula brought back through in the opposite direction. Examination of the shoulder joint showed good articular cartilage on the humeral head. However there were quite large areas of fraying and degeneration of the labrum around the superior and posterior aspects. The anterior labrum appeared intact. The rotator cuff showed no sign of tears. At this point, we inserted a small shaver and cleaned up the posterior labrum, roughening the area underneath to aid healing. Once this was done, we removed the shoulder scope and cannulae and turned our attention to the claviculectomy.

A transverse incision was made across the AC joint and taken down through all layers to the joint itself. The joint was opened and a small elevator used to elevate the soft tissue off the end of the distal clavicle. A small protective retractor was placed beneath it and then an oscillating saw was used to remove approximately one centimeter of the distal clavicle. A rongeur was used to remove some of the soft tissue out of the AC joint. Once this was accomplished, we examined the undersurface of the acromion, where a small sharp osteophyte was rasped smooth.

At the end of the case, we inspected the joint to ensure removal of all impinging tissue. The joint was irrigated with copious amounts of Keflex and normal saline. The fascia overlying the AC joint was closed with 0 Vicryl, subcutaneous tissues were closed with 2-0 Vicryl, and 4-0 PDS was used to close the arthroscopic portals and skin. .25% Marcaine was injected into the joint, the wound was dressed with Adaptic 4 x 4, an ABD pad and foam tape. The patient tolerated the procedure well and left the OR in good condition.

  

    

Using the above patient report(s), do your own coding and then compare it with our coding recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.

 

Please be aware that the Coding Edge® Archive pages are NOT retroactively updated
to reflect possible coding rules and regulation changes made after the publishing date.