# 29825 & 29823 or 29825 & 29826? Newbie to Ortho



## MELJNBBRB (Jun 25, 2014)

Please can someone HELP!
Thanks,
Melissa Bedford,CCS,CPC

PREOPERATIVE DIAGNOSIS: 
Adhesive capsulitis, right shoulder. 

POSTOPERATIVE DIAGNOSIS: 
Same 

PROCEDURES: 
1. Arthroscopic manipulation/lysis of adhesion, right shoulder. 
2. Arthroscopic subacromial decompression right shoulder. 
3. Arthroscopic extensive debridement, right shoulder including biceps tenotomy, supraspinatus, subscapularis and labral debridement. 
4. Injection right shoulder/subacromial space. 
5. Injection right shoulder/glenohumeral joint. 

SURGEON: 
MD 

ASSISTANT: 
xx PA was crucial for the entirety of the procedure. 
There was no qualified resident available. 

ANESTHESIA: 
General with a block. 

ESTIMATED BLOOD LOSS: 
25 mL. 

IV FLUIDS: 
1200 mL. 

INDICATIONS FOR PROCEDURE: 
is a 66 y.o. right hand dominant male with a history of right shoulder pain for the last 9 months without specific injury. Of note he has a history of a left frozen shoulder. Surgery on 10 years ago and is doing well. He reports anterior subacromial pain that is sharp in nature particularly with overhead motion. Rest and activity modification help. He had injections with Dr. x2 the most recent one month ago without relief. He's had physical therapy for 6 weeks is not helpful he had the surgery on his right shoulder. He had a physical exam consistent with adhesive capsulitis. He was advised of the risks and benefits of operative versus nonoperative treatment. He understood those risks and benefits and agreed to proceed with surgery today. 

DESCRIPTION OF PROCEDURE: 
The patient brought to the operating room, placed supine on the OR table, 
underwent general anesthesia without difficulty. Preop time-out was done 
identifying his right shoulder as the operative shoulder. He was placed in a beach chair position with all bony prominences padded. His preoperative range of motion was assessed. He had 90 degrees of abduction with a firm endpoint, 90 degrees of forward flexion with a firm endpoint and 20 degrees of external rotation with a firm endpoint. After receiving general 
anesthesia, he was gently manipulated and the adhesions were lysed with an 
audible pop so that his motion improved to 170 degrees of forward flexion, 
abduction and approximately 80 degrees of external rotation. We then 
prepped and draped in sterile fashion using ChloraPrep. We began the 
diagnostic arthroscopy, using a posterior portal. We immediately proceeded 
to the rotator cuff interval. We made our outside-in portal, began the 
diagnostic arthroscopy with the following findings: His had extensive scarring and synovitis in the shoulder joint. Anteriorly, his whole rotator cuff interval was comprised of scar and his subscapularis was intact with some mild partial tearing as well. Inferiorly, there were no loose bodies in the axillary pouch and 
his anterior labrum was frayed the inferior and posterior labrum were intact. Supraspinatus was also 
intact with only partial tearing. He also had a Type 2 SLAP tear, we performed a biceps tenotomy to help address the SLAP tear. We also debrided the supraspinatus, subscapularis, labrum, and biceps stump back to a stable rim with the shaver. We then turned our attention to the 
resection of the rotator cuff interval, which was made in the triangle 
between the subscapularis, the labrum and what would have been the biceps 
tendon. We resected this with an oscillating shaver and Stryker wand 
back to the level of the coracoid and coracobrachialis. We then entered the subacromial space through the posterior portal and noted diffuse scarring from the acromion to the 
rotator cuff. We introduced the shaver and began resecting the scar 
circumferentially. We did this until the rotator cuff was freed from the 
acromion, both anteriorly and posteriorly with a combination of the 
arthroscopic shaver and Stryker wand. Once this was accomplished, we 
examined the rotator cuff again was intact from the bursal side as well and 
had good stability with internal and external rotation. We then through 
the posterior portal placed a spinal needle under direct visualization to 
make sure it got in the subacromial space and we injected 4 mL of 
ropivacaine, 1 mL of Kenalog to help prevent scar reformation. We then re entered the joint and placed a spinal needle under direct visualization to 
make sure it got in the glenohumeral joint and we injected 4 mL of 
ropivacaine, 1 mL of Kenalog to help prevent scar reformation. Once this 
was accomplished, we removed the arthroscopic tool from the joint and 
closed all portals using interrupted 3-0 nylon stitches in an interrupted 
fashion. Xeroform, dressing sponges, ABD, foam tape and a sling were 
applied. The patient tolerated the procedure well and transferred to 
recovery room in stable condition. 

Postoperatively, he will go same day to physical therapy for aggressive 
range of motion and strengthening of his right shoulder. We want to do this 5 times a week for the first several weeks until his motion has recovered. 
We will see him back in 10-14 days for repeat evaluation and suture 
removal


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## OCD_coder (Jun 25, 2014)

The 29825 bundles and because it is in the same shoulder joint and it is not billable separately.

Billable:
29823
29826


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