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Topic Title: Shoulder surgery for Haglund lesion
Topic Summary: diagnosis coding and CPT coding
Created On: 11/04/2009 07:36 AM

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 11/04/2009 07:36 AM
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Joined: 11/04/2009

If anyone could please help with this one:

Patient was diagnosed with a Haglund lesion and Hill-Sachs deformity - any ideas on ICD.9 codes for these?

In the body of the operative report the physician described the dx as ">>> anterior ligamentous structures were detached from the humerus...."

The procedure he reported: Open capsular shift with anterior ligament repair -

Any ideas on this one for CPT? I know there is an arthroscopic capsular release but I have struggled to find an open capsular shift and anterior ligament repair.

Thank you so much.

Desperate D
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 12/19/2009 06:12 PM
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Joined: 12/19/2009

A hill-sachs lesion is defined as "Indentation or groove on posterolateral aspect of humeral head, probably due to compression of humeral head on posterior lip of glenoid, suggests repeated or chronic anterior shoulder dislocation, may occur after one episode of dislocation associated with: Bankhart lesion of glenoid". For the ICD-9 I recommend 719.91 or possibly 733.99 because of the bony deformity. I use the 719.91 for the Hill Sachs deformity and for a biceps pulley lesion.

As for the CPT - there really isn't enough information provided to accurately code the surgery, but I suggest these two options: 1) 23455 - Capsulorapphy, anterior w. labral repair or possibly 2) 23450 - anterior, putti-platt/magnuson repair. Look at these two codes to see which one best describes the surgery performed.

Sally Roland, MS, RHIA, CPC
Compliance Coordinator - specializing in orthopedics
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