“Osteotomy”…sounds fancy!  Most of the time we code an osteotomy there is a distinct clinical indication and a deliberate surgical technique to fix it.  Examples include acetabular osteotomy for hip realignment, vertebral osteotomy for decompression and realignment, and mandibular osteotomy for bite correction.  These are big surgeries and often the main procedure being coded.

But what about the “lesser tuberosity osteotomy” done in concert with a total shoulder arthroplasty (replacement).  What is it and how do we code it?

To replace a shoulder joint, there must be very good exposure of the glenoid fossa and proximal humerus, which are naturally connected by the rotator cuff tendons and other structures.  Traditionally,  release of the subscapularis (one of the rotator cuff tendons) from the humerus is customary in shoulder replacements for the purpose of exposure of the humeral head and glenohumeral joint.  The usual way is to just cut and then repair the tendon, but better outcomes can be had by performing a thin osteotomy at the insertion of the subscapularis at the lesser tubercle, moving the tendon-plus-bone out of the way, and then replanting the tubercle back on the humerus afterwards.  Bone heals to bone faster and better than cut tendon heals to tendon or to bone.  The subscapularis contributes a great deal to the anterior stability of the shoulder, to prevent instability and dislocation, so a strong repair is important.

The documentation may look something like this:  “A lesser tuberosity osteotomy was then performed with an oscillating saw, removing a wafer of bone with the subscapularis insertion in

place.”  The shoulder joint replacement proceeds.  Then:  “Sutures were placed from lateral and then medial through the lesser tuberosity osteotomy bone, and the subscapularis and tuberosity were reapproximated”.

You will notice the absence of any specific diagnosis or condition to warrant the osteotomy.  That is because it’s only for exposure for the shoulder joint replacement!

PCS guideline B3.1b specifies that procedural steps necessary to reach and close the operative site are not code separately.

CPT is not quite as straightforward as far as a guideline, but the precedent definitely exists.  This is well illustrated by the NCCI policy for the musculoskeletal procedure section, which states, “HCPCS/CPT codes include all services usually performed as part of the procedure as a standard of medical/surgical practice. A physician shall not separately report these services simply because HCPCS/CPT codes exist for them.”

For example, CPT 24400 looks tempting to code additionally, but notice how there is a realignment of the humerus.  Normally when done with a shoulder replacement, the osteotomy is of the lesser tuberosity only, and there is no realignment, and it’s just part of the package. 

Therefore the lesser tuberosity osteotomy should not be coded separately from the shoulder replacement as it’s a necessary step in the main procedure and had no distinct therapeutic intention other than exposure and then restoration to baseline joint stability.

Different surgeons may document this with different degrees of detail, and it may look like the osteotomy is a special procedure but it’s really just a variation of a normal step in a shoulder replacement.

Ed O'Beirne, CCS, CHDA, CHPS, CDIP, PA, MHS

Ed O'Beirne, CCS, CHDA, CHPS, CDIP, PA, MHS

Director of Clinical Integration

Ed has been in healthcare his entire career with 15 years as a clinician and 11 years in a variety of HIM coding related roles. After 4 years as a respiratory therapist and 11 years as an emergency medicine Physician Assistant, the fascination with reading, analyzing, and translating medical documentation overcame his desire to perform patient care. For a guy who with a habit for reading the Encyclopedia Brittanica, the Merck Manual, and medical records just for fun, HIM became a natural fit.

Documentation and coding audits are firmly in Ed’s skillset but educating coders is what really makes him tick. He is known for effectively integrating anatomy, physiology, pathophysiology, medicine, and detailed procedural descriptions into his coding education in all forms.

He is a BS graduate in Biology from Virginia Commonwealth University and Master of Health Sciences from Duke University. Obsessed with aviation, he has a pilot’s license, 1000 skydives, owned an ultralight for several years, and currently designs, builds, and flies radio controlled airplanes and drones. Ed lives in Virginia with his wife and two kids, and plays outside with them as much as possible.

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