Shoulder¶

· Entry of treatment code ‘Other repair of shoulder including acromioplasty or subacromial depression’ includes removal of a part/portion of the acromion

· The acromion is the top or upper portion of the shoulder blade (scapula)

· The medical code is 81.83.L/R

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Bankhart Lesion/Bankhart Tear¶

· Involves the labrum and is a tear of the anterior labrum; in the system the SLAP injury code is used for these

· A Bankhart Lesion/Tear is often associated with an anterior shoulder dislocation (where the humerus detaches from the glenoid cavity); if this is the case enter both the SLAP and the shoulder dislocation codes

· Medical code 840.7.L/R

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Clavicle resection (Mumford Procedure, Claviculectomy)¶

· Shoulder surgery often includes a resection of a piece of the clavicle. Often this procedure is referred to as ‘resection of distal clavicle’, ‘partial claviculectomy’ or ‘partial resection of the clavicle’; it is also sometimes referred to as a Mumford Procedure

· A ‘claviculectomy’ is an excision of the clavicle. Typically, it is a partial excision which involves the distal portion of the clavicle

· The code in the system that covers a claviculectomy is 77.81.AL/AR Other partial ostectomscapula, clavicle

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Coracoacrominal Ligament Release partial or full¶

· Entered in the system using code 83.13.C1L/R Other tenotomleft/right shoulder

· In the system the terms ligament and tendon are interchangeable

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Debridement of Labrum¶

· Much like a rotator cuff tear, a tear of the labrum does not always require a repair. Frequently the torn/frayed edges can be removed or debrided

· In the system, debridement of the labrum is entered as ‘Other local excision or destruction of lesion-shoulder’

· The root code is 80.81

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Dislocation Shoulder¶

· A shoulder dislocation is where the humerus separates from the glenoid cavity/fossa which is part of the scapula

· Shoulder Dislocation uses 831 series of codes

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Glenohumeral Dislocation/Shoulder Dislocation¶

· Entered in the system using the 831.0 (closed) or 831.1 (open) series of codes

· Shoulder dislocations can be anterior, posterior or inferior

· Anterior Glenohumeral Dislocation is the most common

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Myectomy (excision of muscle; also used for debridement of muscle)¶

· A rotator cuff tear does not always require a repair; depending on the severity of the tear a myectomy (a debridement, or shaving away of the damaged/torn portion of the muscle) may be performed

- Entered in the system using code 83.45.C1L/R – Other myectomy – left/right shoulder

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Rhomboid Strain¶

· The rhomboid muscle is located in the shoulder region

· It attaches to the lower 2/3 of the medial/vertebral border of the scapula to the inferior angle

· A diagnosis of rhomboid strain is entered in the system as a shoulder sprain/strain

· Use the 840.8 series of codes described as ‘shoulder-sprain/strain teres minor or other muscle/tendon’

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Rotator Cuff Capsule¶

· The rotator cuff capsule is a separate structure in the shoulder from the rotator cuff muscle

· The capsule covers the shoulder joint

· Rotator cuff capsule is found on Blue Person Search under the injury category of Rotator Cuff Capsule when the shoulder is selected

· Freeform search enter keywords ‘rotator cuff capsule’ as injury type

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Rotator Cuff Muscle Sprain/Strain (Partial tear or tear)¶

· The rotator cuff muscles cover the capsule

· There are four rotator cuff muscles : supraspinatus; infraspinatus; subscapularis ; and teres minor. Enter the specific muscle involved, MRI reports or x-rays are an excellent source for determining the correct muscle

· If there is a partial or complete tear of a rotator cuff muscle and surgery is done to repair the muscle, then this is, for the purpose of the system, considered a severe sprain/strain

· Freeform search enter the name of muscle injured, severity of sprain (minor, moderate or severe) and left (l) or right (r)

· Blue Person search under the injury category of Sprain/Strain when the shoulder is selected

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Scapulectomy¶

· A Scapulectomy is the surgical removal of the scapula which is the flat, triangular bone located in the back of the shoulder commonly referred to as the shoulder blade

· An ostectomy is the surgical removal of bone so a Scapulectomy is also referred to as an ostectomy of the scapula

· The treatment code can be located in the system via freeform search using the keywords ‘ostectomy scapula’

· The code is ‘77.81.AR/AL – Other partial ostectomy right/left scapula, clavicle’

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Shoulder Separation or Acromioclavicular Joint/Ligament Separation/AC Separation¶

· Shoulder separation or AC joint separation is an injury to the joint between the scapula and clavicle

· AC refers to the acromioclavicular joint/ligament. The AC joint is the junction of the acromion (the end of the scapula) and clavicle and is held in place by three ligaments. The separation may be diagnosed as an

o Acromioclavicular separation

o Acromioclavicular joint separation

o AC joint separation

· AC Separations are generally graded as minor (Grade I), moderate (Grade II) or severe (Grade III)

· The severe, or Grade III, separation is considered a dislocation as it involves complete separation of the clavicle and scapula

· The minor and moderate acromioclavicular joint/ligament sprain/strain codes are used for a Grade I or II Separation

· The codes available in the system for AC separation can be located via freeform search using the key word ‘acromioclavicular’ or ‘acromio’

· The dislocation code should be used if there is a severe AC separation

· ‘Dislocation shoulder - Acromioclavicular (joint)’ is used for a true dislocation , or complete separation of the clavicle and scapula (Grade/Type III, IV, V or VI AC Separation). A severe AC separation may also be referred to as a Grade IV, V or VI separation

· Closed Dislocation codes 831.04.L/R

· Open Dislocation codes 831.14.L/R

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SLAP (Superior Labrum Anterior to Posterior)¶

· Is a labrum tear - a tear of the superior (top) of the labrum from the front to back

· SLAP is found in the Blue Person Search under the Injury category of Sprain/Strain when the shoulder is selected

· Freeform enter keyword ‘SLAP’ as an injury type. The code is described as Superior Glenoid labrum lesion of shoulder.

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Trapezius Sprain¶

· The trapezius muscle runs from the base of the neck down to the shoulder blade and upper back

· Frequently, a trapezius sprain/strain is diagnosed in conjunction with a cervical sprain/strain

o It may be only necessary to enter the cervical sprain/strain since trapezius is part of the neck

· Each case should be assessed on its own merits along with a complete review of the medical records in order to determine the injury

· If a trapezius sprain is diagnosed, it is entered in the system as 'shoulder-sprain/strain-teres minor or other muscle/tendon'

· The root code is 840.8 and the code selection will depend on the severity of the sprain/strain

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Shoulder Medical Codes¶

INJURIES¶

Labral (Labrum) Tear	840.7.L/R
SLAP Lesion/Bankart Lesion	840.7.L/R

Shoulder Separation/AC Separation (Rupture)/Knocked-down Shoulder/AC
Dislocation
· Minor/Grade I/Type I	840.0.AL/AR
· Moderate/Grade II/Type II	840.0.BL/BR
· Severe/Grade III/Type III	831.04.L/R (closed) / 831.14.L/R (open)
Shoulder Dislocation (humerus dislocates from scapula)	831 series of codes
Trapezius sprain/strain (minor, moderate or severe)	840.8.AL/R, BL/R, CL/R

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COMPLICATIONS¶

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¶

---|--- Bursitis/Subacromial Bursitis | 726.10.BL/BR Frozen Shoulder/Adhesive Capsulitis | 726.0.L/R Impingement Syndrome/Shoulder Impingement/Chronic Tendonitis | 726.11.BL/BR Rotator Cuff Syndrome/Rotator Cuff Disease | 726.10.L/R Rotator Cuff Tendonitis/Shoulder Tendonitis/Acute Tendonitis | 726.11.AL/AR

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TREATMENTS¶

Acromioclavicular Resection	77.81.AL/AR
Arthrectomy/Arthrotomy of Shoulder	80.11.L/R
Arthroplasty/Glenoplasty	81.83.1L/R
Arthroscopy	80.21.L/R
Bristow Repair/Bankart Repair/Putti Platt Procedure	81.82.L/R
Bursectomy/Removal of Bursa	83.5.C1L/C1R
Debridement of the Labrum	80.81.L/R
Debridement of Rotator Cuff Muscle(Myectomy)	83.45.C1L/C1R
Division of Joint Capsule Ligament or Cartilage/Chondrectomy (Removal of Cartilage)	80.41.L/R
Rotator Cuff Repair/Repair Musculotendinous Cuff	83.63.L/R
Excision of Clavicle/Claviculectomy/Resection Distal Clavicle (Munford Procedure)	77.81.AL/AR
Fusion of Shoulder/Arthrodesis	81.23.L/R
Joint Aspiration/Arthrocentesis	81.91.1L/R
Other Repair of Shoulder/Acromioplasty	81.83.L/R
Scapulectomy	77.81.AR/AL
Shoulder Replacement (Partial or Complete)/Hemiarthroplasty	81.81.L/R or 81.80.L/R
SLAP Repair	81.83.L/R
Subacromial Decompression	81.83.L/R
Synovectomy	80.71.L/R

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