5/7/2009 SHOULDER) CONDITIONS OF THE SHOULDER NOW IT TIME TO TEST YOU ICD-9 SKILLS: PLEASE APPEND THE APPROPRIATE DIAGNOSIS CODE FOR EACH:

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1 SHOULDER CONDITIONS OF THE SHOULDER AND THEIR TREATMENT Presented by Kevin Solinsky, CPC,CPC-I,CEDC, CEMC The is a major joint and plays a large part in daily life, particularly for athletes and those who perform a lot of lifting and reaching as part of their jobs. Orthopedic surgeons frequently see injuries, which can be extremely painful and are often difficult to treat. The following list outlines some of the most common diagnoses. SHOULDER CONDITIONS AC Joint Separation Adhesive Capsulitis (Frozen Shoulder) Arthritis Bankart Lesion Bursitis/Tendonitis/Impingement Syndrome Shoulder bursitis Rotator Cuff Tear Shoulder Instability/Dislocation SLAP Lesion NOW IT TIME TO TEST YOU ICD-9 SKILLS: PLEASE APPEND THE APPROPRIATE DIAGNOSIS CODE FOR EACH: AC Joint Separation Adhesive Capsulitis (Frozen Shoulder) Arthritis Bankart Lesion Bursitis/Tendonitis/Impingement Syndrome Shoulder bursitis Rotator Cuff Tear Shoulder Instability/Dislocation SLAP Lesion AC JOINT SEPARATION A separation of the acromioclavicular (AC) joint (831.4, Dislocation of ; acromioclavicular [joint]), also called a separation, occurs when the clavicle and scapula separate due to a strain, sprain or tear of one or more ligaments in the. In the most serious form of AC joint separation, both the acromioclavicular ligament and the coracoclavicular ligament are completely torn. These injuries often occur following a fall or a direct blow to the, often during sports, and can cause intense pain. If the injury is considered a grade 1 separation (a sprain without tearing of the ligaments) or a grade 2 separation (with partial tearing of the ligament[s]), surgeons usually prescribe pain medication and stabilize the joint using a sling. If the patient suffers a grade 3 separation with tearing of both ligaments and does not respond well to conservative treatment, the surgeon may opt to perform an AC joint stabilization surgery, also known as a Weaver-Dunn reconstruction (23550, Open treatment of acromioclavicular dislocation, acute or chronic). ADHESIVE CAPSULITIS (FROZEN SHOULDER) When thick bands of tissue (adhesions) grow around the joint, patients suffer from adhesive capsulitis (726.0, Adhesive capsulitis of ). The condition is also known as frozen because the associated lack of synovial fluid prevents the from moving properly. Physicians usually have success treating this condition with conservative treatment such as cortisone injections, physical therapy, NSAIDs, but some patients still require surgery. Surgeons can sometimes treat adhesive capsulitis using manipulation under anesthesia (23700, Manipulation under anesthesia, joint, including application of fixation apparatus [dislocation excluded]). However, some patients conditions are so severe that they require an arthroscopic capsular release (29823, Arthroscopy,, surgical; debridement, extensive). 1

2 ARTHRITIS BANKART LESION Although arthritis ( for osteoarthritis, for rheumatoid arthritis) is less common than arthritis in the knees and hips, it can be unbearably painful for patients afflicted with it. The initial symptoms include stiffness, swelling and pain in the. Conservative treatment usually includes rest, NSAIDs, physical therapy and corticosteroid injections. If conservative treatment fails, the physician may perform arthroscopic surgery (such as acromioplasty, 23130). Although the procedure does not completely cure the arthritis, it does relieve the patient s symptoms. In some cases, the surgeon may perform a total replacement, for which you should report (Arthroplasty, glenohumeral joint; total [glenoid and proximal humeral replacement [e.g., total ]). A Bankart lesion is a tear of the rim below the middle of the glenoid socket that also involves the inferior glenohumeral ligament. Tears or lesions of this type often occur together or with dislocation and rotator cuff tears. They often occur as a result of a fall on an outstretched arm. In throwing sports, such as baseball, football, etc., injuries of this type are extremely common. Surgeons usually diagnose Bankart lesions using an MRI with contrast. The ICD-9 Manual does not list a diagnosis code for a Bankart lesion. However, Bankart lesions usually result from a traumatic dislocation, so you should use the dislocation code (831.0x) to identify the patient's original problem. If the Bankart lesions appear following a chronic problem, recurrent dislocations (718.31) or instability (718.81) is usually the cause. If rest and physical therapy do not relieve the patient s symptoms, the orthopedic surgeon may opt to perform surgery. The surgeon will most likely perform Bankart repair (23455 for an open procedure, or for arthroscopic repair) TENDONITIS/IMPINGEMENT SYNDROME Shoulder impingement syndrome (726.2, also known as rotator cuff impingement) occurs when a tendon or bursa is compressed or pinched. Bursitis ( and tendonitis are related to impingement syndrome, and can occur together. Impingement is common in athletes who perform activities that involve frequent reaching over the head, such as swimming or playing tennis. If a patient suffers from tendonitis of the, his rotator cuff and/or biceps tendon become inflamed, resulting in pain and swelling. Many patients, particularly athletes, suffer from overuse tendonitis (726.10). This means that the tendons are irritated, bruised or fraying due to repetitive motions during sports, frequent lifting, or other overhead activities. Other patients experience calcific tendonitis (726.11), which means that calcium deposits have accumulated in the tendons, leading to pain and loss of motion. SHOULDER BURSITIS Shoulder bursitis (726.10) occurs when the bursa (a fluid-filled sac) in the rotator cuff becomes inflamed. This can cause swelling, redness, pain and a loss of motion. Bursitis can lead to impingement because the swelling and inflammation can cause the tendons and bursa to become pinched between the bones. Possible remedies: Surgeons typically use bursa injections (20610), physical therapy, and NSAIDs to treat these conditions. If conservative treatments fail, the surgeon may suggest subacromial decompression with anterior acromioplasty (29826). ROTATOR CUFF TEAR SHOULDER INSTABILITY/DISLOCATION The rotator cuff is a group of muscles that work together and help the to remain stable. The muscles are the subscapularis, supraspinatus, infraspinatus and teres minor. Patients can suffer acute tears of the rotator cuff or chronic tears, and both types of rotator cuff tears (727.61) have their own special treatment options and recovery periods Acute Rotator Cuff Tear: Acute tears usually happen suddenly, as a result of a fall or a sudden jerking movement (such as throwing a football very hard). This will cause sudden pain and weakness, and possibly a snapping feeling. Chronic Rotator Cuff Tear: Chronic tears usually exhibit symptoms over time, going from mild pain to severe pain and inability to lift the arm above the head. These tears can be a result of overuse or wear and tear. Although some rotator cuff tears can be managed with physical therapy, rest and stabilization, more severe tears may require surgical rotator cuff repair ( , for open procedures). In some cases, the surgeon may choose to perform the repair arthroscopically (29827). Shoulder instability (also known as loose ) is caused by a subluxation (partial dislocation) that causes the ball of the joint to become unstable anteriorly because the ligaments and muscles are overstretched. The surgeon will probably perform an x-ray or MRI to confirm diagnosis of instability (718.81). If the patient s does not heal, or if the patient suffers a complete dislocation ( ) the surgeon may choose to perform surgery, such as a closed dislocation repair (23650) or arthroscopic thermal capsulorrhaphy (29806). A dislocation is the most commonly dislocated joint in adult patients. 2

3 SLAP LESION A SLAP lesion (840.7) is a tear of the Superior Labrum, Anterior to Posterior (SLAP). The labrum is piece of cartilage that deepens the socket (glenoid) of the joint. The anterior-inferior portion of the labrum can be torn when the dislocates forwardly, causing the SLAP lesion. Patients can get a SLAP lesion after falling down, or following repeated overhead actions such as throwing a football. Symptoms include pain, swelling and an occasional clicking sound when moving the arm in a throwing position. Most physicians recommend rest and NSAIDs initial treatment for this condition. However, surgery is often required to repair the SLAP lesion (29807 for arthroscopic repair or for open repairs). MORE ICD-9 CODING A 16 year old male high school basketball player sustained fracture to his right several months ago, he now presents with instability and dislocation in his region. Physician recommends he undergo repair for instability, during arthroscopic examination it is determined the patient has a Hill Sachs Lesion in the right which is repair. What is the appropriate diagnosis? LAST ONE A 57 year old female presents with ongoing problems with her, she has had symptoms of pain and limited motion for over one year. She undergoes arthroscopic surgery; physician findings indicate she has degenerative tearing of her rotator cuff, impingement of the, and inflammation of the bicipital tendon. Which of the following appropriately describe her condition? 726.2, , , , , , , HISTORY Arthroscopy is a surgical technique developed by a Tokyo doctor, Dr. Masaki Watanabe, in the early 1960s to permit orthopaedic surgery in a relatively noninvasive way. Based on a cystoscope, In 1964, a 32-year-old orthopaedic surgeon with the Canadian team at the Tokyo Olympics - Dr. Robert Jackson, learned the technique and brought it to North America. Greek word Arthro Joint Skopein to look Provides surgical access without the exposure of open Quicker healing 3

4 Make a small incision in the patient's skin insert pencil-sized instruments Have a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope Attach the arthroscope to a miniature television camera INDICATIONS FOR Most frequent conditions found during arthroscopic examinations of joints are: Synovitis Loose bodies of bone and/or cartilage INDICATIONS FOR SHOULDER Injuries - acute and chronic Shoulder - rotator cuff tendon tears, impingement syndrome, and recurrent dislocations SHOULDER PROBLEMS TREATED WITH COMBINATION SURGERY Rotator cuff procedure Repair or resection of torn cartilage Removal of inflamed lining (synovium) in Repair of torn ligaments Removal of loose bone or cartilage in CODING QUESTION The doctor stated he performed diagnostic arthroscopy of the glenohumeral joint followed by arthroscopic repair of the superior labrum Following this, open reconstruction of the AC joint with distal clavicle excision and a Weaver/Dunn reconstruction; acromioplasty. Need help finding proper CPT codes. 4

5 ANSWER Diagnostic arthroscopy of the glenohumeral joint followed by arthroscopic repair for the superior labrum: 29807, Arthroscopy,, surgical; repair of slap lesion. A slap lesion is an injury to the labrum that extends from anterior to the biceps tendon to posterior to the biceps tendon. Open reconstruction of the AC joint with distal clavicle excision and a Weaver/Dunn reconstruction; acromioplasty: 23130, Acromioplasty or acromionectomy partial, with or without coracoacromial ligament release and 23120, Claviculectomy; partial. Without further description of the reconstruction, I can not give you a more specific code. But based upon your description, these codes will be appropriate. QUESTION Why is there no cpt code for the diagnostic arthroscopy?? PREOPERATIVE DIAGNOSES: 1. Torn right rotator cuff (massive tear) including subscapularis, supraspinatus, infraspinatus and teres minor muscles. 2. Biceps tendon medial dislocation. 3. Degenerative joint disease-severe right acromioclavicular joint. 4. Chronic subacromial impingement syndrome. PROCEDURE PERFORMED: 1. Arthroscopic rotator cuff repair, subscapularis, supraspinatus, infraspinatus, and teres minor muscles. 2. Arthroscopic biceps tenodesis. 3. Arthroscopic subacromial decompression. 4. Arthroscopic distal clavicle resection (Mumford procedure). SURGEON: ASSISTANT: ANESTHESIA: GENERAL COMPLICATIONS: NONE OPERATIVE TECHNIQUE: The patient was identified, brought to the operating suite, and place supine on the operating table. The patient then underwent successful induction of general anesthesia. Following this, the patient's right upper extremity was examined under anesthesia and was found to exhibit full passive range of right right motion with no instability to anterior, inferior, posterior ligamentous stress testing. The patient was transferred to the left lateral decubitus position on the beanbag floatation apparatus. Care was taken to protect the patient's bony prominences through the procedure. The patient's right upper extremity was then suspended from an Acufex suspension apparatus with 10 lbs of distraction applied at the patient's right forearm through use of a sterile Buck traction sleeve. A standard posterior arthroscopic portal was created through which a 30-degree oblique-viewing arthroscope was inserted. The entire glenohumeral joint was distended with lactated Ringer's using an arthroscopic pump. The biceps tendon was dislocated medially. There was a massive rotator cuff tear involving the supraspinatus, infraspinatus, teres minor muscles as well as the subscapularis superior aspect. The humeral head and glenoid fossa articular surfaces were unremarkable. The glenoid labrum circumferentially exhibited minor fraying. There was hypertrophic hyperemic chronic synovitis within the glenohumeral joint. An accessory anterior arthroscopic portal was created through the rotator interval, and a complete synovectomy was performed with a motorized shaver. The arthroscope was then withdrawn and reinserted in the subacromial space where dense fibrous tissue adhesions were encountered. An accessory anterolateral arthroscopic portal was created and a motorized shaver was used and a complete subacromial bursectomy was also performed. The CA ligament was detached from the acromion process and was excised with electrocautery and a motorized shaver. Acromioplasty was performed resecting a large anterior inferior medial acromion osteophyte. The distal clavicle revealed severe DJD, and therefore the distal 1.5 cm of clavicle was also resected with a motorized bur. The rotator cuff was extensively debrided back to healthy vital tissues. Extensive operative time and soft tissue dissection was necessary to provide mobilization of sufficient rotator cuff to allow a tendon-to-tendon and tendon- to-bone anatomic repair. Two rows of Bioabsorbable Corkscrew suture anchors were then placed in the greater tuberosity and the superior aspect of the lesser tuberosity, which were both debrided with a motorized bur. The sutures were passed through the rotator cuff, subscapularis initially, which was repaired to the lesser tuberosity, and then the supraspinatus, infraspinatus and teres minor muscles achieving anatomic tendon- to-bone repair. The biceps tendon which was dislocated medially was detached from the superior glenoid tubercle and was tenodesed to the lateral aspect of the greater tuberosity and the bicipital groove. Finally, the teres minor was further repaired in a side-to-side fashion using a single #2 FiberWire suture. An anatomic tendonto-bone and tendon-to-tendon repair was achieved under minimal tension. There were no additional subacromial impingement sites noted throughout full passive range of motion. The arthroscope, instruments, and cannula were then removed after having placed an indwelling pain infusion catheter in the subacromial space under direct arthroscopic visualization. The arthroscopic portals were closed in a routine fashion, and the patient had a well-padded gentle sterile compressive dressing applied incorporating the postop surgery stim pads. The patient was placed in large abduction pillow splint for support, had reversal of the general anesthetic, and was transferred to the recovery room in good condition. PREOPERATIVE DIAGNOSES 1. Chronic right subacromial impingement syndrome with possible partial versus small fullthickness rotator cuff tear. 2. Degenerative joint disease right acromioclavicular joint. 3. Chronic synovitis. POSTOPERATIVE DIAGNOSES 1. Chronic subacromial impingement syndrome, right, no evidence of rotator cuff tear. 2. Degenerative joint disease, severe, right acromioclavicular joint. 3. Chronic synovitis right glenohumeral joint anterior, superior, posterior, inferior regions. 4. Anterior superior degenerative labral tear. PROCEDURES 1. Arthroscopic right decompression. 2. Distal clavicle resection (Mumford procedure). 3. Complete synovectomy anterior, superior, posterior, inferior regions. 4. Extensive debridement anterior superior degenerative labral tear. ANESTHESIA: General. COMPLICATIONS: None. OPERATIVE TECHNIQUE: The patient was identified and brought to the operating suite and placed supine on the operating table. The patient then underwent successful induction of general anesthesia. Following this, the patient's right upper extremity was examined under anesthesia and was found to have a full passive range of right motion with no instability anterior, inferior, posterior ligamentous stress testing. The patient was transferred to the left lateral decubitus position on a beanbag flotation apparatus. Care was taken to protect the patient's bony prominences throughout the procedure. The patient's right upper extremity was then prepped and draped in the usual sterile fashion for surgery about the right. The right upper extremity was suspended from an Acufex suspension apparatus with 10 pounds of traction applied to the patient's right forearm through use of a sterile Bucks traction sleeve. The patient's right was examined arthroscopically using a standard posterior arthroscopic portal through which a 30-degree oblique-viewing arthroscope was inserted. The entire glenohumeral joint was distended with lactated Ringers using gravity inflow. The biceps tendon was intact. The undersurface of the rotator cuff, supraspinatus, infraspinatus, and teres minor muscles were intact. The humeral head and glenoid fossa articular surfaces were unremarkable. The glenoid labrum circumferentially exhibited anterior, superior labral degenerative tear, but the biceps anchor was intact. The middle and inferior glenohumeral ligaments were intact. There was hypertrophic hemorrhagic hyperemic synovial hypertrophy anteriorly, superiorly, posteriorly, and inferiorly. An accessory anterior arthroscopic portal was created through the rotator interval and a motorized shaver was introduced and a complete synovectomy anteriorly, superior, posterior, and inferiorly was carried out. In addition, extensive debridement to the anterior, superior labral tear was also carried out. The arthroscope was then withdrawn and reinserted in the subacromial space where dense fibrous tissue adhesions were encountered. An accessory anterolateral arthroscopic portal was created and complete decompression was performed. The CA ligament was detached from the acromion process and was excised with electrocautery and a motorized shaver. The acromioplasty was performed with a motorized bur resecting a large anterior inferior medial acromion osteophyte. The distal clavicle revealed severe degenerative joint disease and therefore the distal clavicle was resected with a motorized bur resecting the distal 1.5 cm of clavicle to the level of the CA ligament which was intact. Hemostasis was achieved with electrocautery. The superior surface of the rotator cuff was inspected and revealed no bursal-sided rotator cuff tear. The arthroscope, instruments, and cannula were then removed. The arthroscopic portals were closed in routine fashion, and the patient had a well-padded, gentle sterile compression dressing applied incorporating the postoperative Surgi-Stim pads. The patient was placed in an arm sling for support and had reversal of the general anesthetic, and was transferred to recovery room in good condition. QUESTIONS??? 5