© Copyright 2025 American Medical Association. All rights reserved.
An open treatment of shoulder dislocation with a fracture of the greater tuberosity of the humerus involves a surgical procedure where the dislocated shoulder is repositioned, and any associated fracture of the greater tuberosity is addressed. The greater tuberosity is a bony prominence on the humerus where the rotator cuff muscles attach. In cases of fracture-dislocation, this area may become displaced, leading to retraction of the rotator cuff musculature, which can complicate the dislocation. The procedure typically requires a deltopectoral approach, which allows for direct access to the shoulder joint. During the surgery, the clavipectoral fascia is divided to facilitate exposure, and the surrounding anatomical spaces are developed to provide a clear view of the joint structures. The axillary nerve, which innervates the deltoid muscle and provides sensation to the skin overlying the shoulder, is carefully located and protected throughout the procedure to prevent injury. The long head of the biceps tendon is also identified and followed to the rotator interval, which is opened to access the dislocated structures. The surgical team will then identify the displaced bone fragment of the greater tuberosity and secure it using sutures at the junction where the tendon attaches to the bone. Additional fixation techniques, such as drilling holes in the humeral shaft and passing sutures through these holes, may be employed to enhance stability. The humeral head and lesser tuberosity are then reduced and fixed, followed by the reduction and fixation of the greater tuberosity fracture. This may involve the use of sutures, staples, or internal fixation devices like wires, plates, or screws. After addressing the fracture, any damage to the rotator cuff is repaired to restore function and stability to the shoulder joint.
© Copyright 2025 Coding Ahead. All rights reserved.
The open treatment of shoulder dislocation with a fracture of the greater tuberosity is indicated in the following scenarios:
The procedure involves several critical steps to ensure proper treatment of the shoulder dislocation and associated fracture:
After the procedure, the patient will typically require a period of recovery, which may include immobilization of the shoulder to allow for healing. Pain management and rehabilitation exercises will be initiated as per the surgeon's recommendations. The patient will be monitored for any signs of complications, such as infection or improper healing of the fracture. Follow-up appointments will be necessary to assess the healing process and to guide the rehabilitation program aimed at restoring range of motion and strength in the shoulder.
| Short Descr | OPTX SHO DISLC FX | Medium Descr | OPTX SHO DISLC W/FX GR HUMERAL TUBRST INT FIXJ | Long Descr | Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 148 - Other fracture and dislocation procedure |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2023-01-01 | Note | Short and medium descriptions changed. |
| 2008-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.