I am new to Orthopedic coding and would like some help with how to code the following:
Excision of subacromial bursa
Excision of coracoacromial ligament
This was done as an open procedure. Can someone help me, Im not sure if any of these are content of service to another, or if they are 4 separate procedures. This is how I think it should be coded, but I would like professional advice as to if this is correct .I would use 23120, 23130-51, 23415. Please advise as soon as possible.. Thanks
An incision was made on top of the right shoulder, the skin and subcutaneous tissue were incised and all the bleeders were properly cauterized, meticulous attention was placed to identify the plane between deltoid anteriorly and trapezius posteriorly. We incised at the level of the acromioclavicular joint. When this was identified, , we identified the acromion and the acromion had a large osteophyte going downwards and impinging upon the rotator cuff. We proceeded to do first a Mumford procedure, and thus, excising the later 1.5 cm of the clavicle. Subsequent to this, we removed the undersurface of the acromion with the osteophyte and then, by utilizing our rods with___perfectly clear. When that had been accomplished, we removed a large and exuberant subacromial bursa as well as the coracoacromial ligament. When that had been done, we put 2 Army-Navy retractors, 1 anterior into the deltoid and 1 laterally also at the level of the ___ and acromion. We examined the rotator cuff completely. There was no evidence of any tears, only some evidence of tendonitits at the level of the impingement with no partial or complete tears all the way into the insertion of the rotator cuff into the greater tuberosity. Under these circumstances we irrigated with copious amounts of saline solution with antiobiotic and then we closed the interval between trapezius and deltoid going through the acromion and that was done with a figure-of-eight #1 Surgilon, The we closed the subcutaneous tissue with 2-0 chromic and, finally, the skin with a running stich of 3-0 nylon.