You are watching: Icd 9 code for labral tear
Even experts can floor on the dorn ICD-9 password for SLAP lesion repair, but visualizing the injury an ar as a clock will help you identify one form of SLAP (superior labral anterior posterior) tear indigenous another.
Research Patient history for accurate Diagnosis
Having a solid understanding of anatomy and also knowing the severity of the patient’s case give your coding a certain foundation.
Define it: The labrum is the rim of cartilage that deepens the shoulder socket (glenoid) and increases share stability. The superior portion of the labrum have the right to be torn once the shoulder dislocates forwardly (anteriorly). This outcomes in a SLAP lesion — a tear the the exceptional labrum, anterior come posterior, states William J. Mallon, MD, an orthopedic surgeon and also medical manager of Triangle Orthopaedic Associates in Durham, N.C.
Patients can gain a SLAP lesion after ~ falling down, or complying with repeated overhead plot such together throwing a football. Symptoms include pain, swelling, and also an occasional “clicking” sound when relocating the arm in a cram position.
Diagnose it: The diagnosis you submit counts on the physician’s clinical diagnosis and whether the injury is acute or chronic. 2 of the most typical diagnoses you’ll encounter are:
• because that acute injuries, use 840.7 (Sprains and also strains that shoulder and also upper arm; remarkable glenoid labrum lesion) . “Code 840.7 calls for an injury date, for this reason be certain the doctor notes the in the patience record,” Mallon says.
• code 718.01 (Articular cartilage disorder; shoulder region) uses to chronic or degenerative injuries.
Avoid this: Coders sometimes report 718.81 (Other joint derangement, not somewhere else classified; shoulder region) for SLAP lesions, yet that’s no your best choice because the labrum is not articular cartilage. 718.01 is more accurate because that chronic or degenerative SLAP lesions for instability.
Verify Injury’s Severity to determine Level
Four species of SLAP lesions room clinically important for your coding purposes. SLAP lesions variety from degenerative fraying of the labrum to extension of the SLAP lesion beneath the center glenohumeral ligament. Each form describes tears that the labrum or work-related done on specific sections that the glenohumeral (GH) joint capsule. Your code an option will hinge top top the form of SLAP lesion and whether your surgeon performs debridement or repair. Possible codes because that reporting based on the operation procedure include:
• form I — 29822 (Arthroscopy, shoulder, surgical; debridement, limited)
• form II — 29807 (Arthroscopy, shoulder, surgical; fix of SLAP lesion) for arthroscopic repair of a SLAP lesion. “Note the this code is certain for SLAP repair,” claims Cristina Bentin, CCS-P, CPC-H, CMA, founder of Coding Compliance monitoring in Baton Rouge, La. “Unless verified that this is a SLAP, 29807 is no reported for labrum tears that are not especially SLAP tears.”
• type III — 29822 or 29807, relying on the level of injury and your physician’s approach
• form IV — Coding for a form IV SLAP lesion different according to the procedure performed. Documentation describe a SLAP repair could warrant 29807, Bentin says. However, other procedures performed in combination with the SLAP repair might justify 29807 in enhancement to various other codes. “With kind IV SLAP lesions, most surgeons proceed to arthroscopic biceps tenotomy or biceps tenodesis,” Mallon says. Report biceps tenodesis v 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis). CPT go not incorporate a code for arthroscopic tenotomy, so you would report 29999 (Unlisted procedure, arthroscopy) uneven the operated doctor completes other job-related in the area the justifies extr or alternative codes. Because that example, Mallon states to code the procedure through 29823 (… debridement, extensive) because that debridement that both the anterior and also posterior compartments of the GH joint.
Watch: Types II and also IV SLAP lesions undergo surgical repair many often; her physician have the right to treat the other species of lesions through debridement rather than repair. The surgeon’s documentation must support the type of SLAP lesion being repaired and will recognize the code you assign. Look for information about the kind of SLAP lesion treated and whether the surgeon debrided both the anterior and also posterior compartments of the GH joint.
Let the Clock narrow Your Choices
Orthopedic surgeons regularly use clock face terminology as soon as describing the place of a labral tear or ligamentous losing or laxity, claims Heidi Stout, CPC, CCS-P, manager of orthopedic coding services at The Coding Network LLC. They could make statements in their operative reports such together “the labrum was checked out to be detached indigenous 3 o’clock come 6 o’clock.” yet what walk that sort of documentation mean?
Imagine a clock confront and snapshot where every number is. Currently imagine that clock challenge as the shoulder joint. Stout claims that labral tears that occur in the area native 10 o’clock come 2 o’clock are described as SLAP lesions.
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“Report 29807 once your surgeon repairs a lesion in between the 10 o’clock and 2 o’clock positions,” Stout says. “If the surgeon does not usage the hatchet ‘SLAP lesion’ however describes repair of a superior labral tear in between 10 o’clock and 2 o’clock, you have the right to use 29807.”
Double check: You can want to ask her surgeon for confirmation that he did complete a SLAP procedure before reporting 29807 in the latter scenario.