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JustCoding News: Inpatient, November 11, 2009

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A patient was diagnosed with a Haglund lesion and Hill-Sachs deformity. What ICD-9 codes should we report? In the operative report, the physician described the diagnosis with the following documentation: “Anterior ligamentous structures were detached from the humerus.” For the procedure, the physician documented, “open capsular shift with anterior ligament repair.” What CPT code should we report? I know there is an arthroscopic capsular release, but I have struggled trying to find a code for an open capsular shift and anterior ligament repair.

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