Hi list,
Need some guidance, pt is 60 years old here is his HPI
below )
Would you consider this acute or chronic?
23410 vs 23412
Additionally you cannot code 29826 with 23410 or 23412, so I chose 29822.
I am gathering the biceps tendodesis was done open? 23430 vs arthroscopic 29828?
Thanks Melissa Bedford,CCS,CPC
History of Present Illness
HPI patient presents c/o left shoulder pain. Had been having minor pain, but worsened after pulling object. Since then, has pain using 2 fingers to open a drawer or just reaching out to open the refrigerator
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Arthroscopy of the left shoulder, subacromial decompression.
2. Mini open rotator cuff repair.
3. Biceps tenodesis.
COMPLICATION OF THE PROCEDURE:
None.
SPONGE AND NEEDLE COUNT:
Correct.
DRAIN:
No drain was used.
INDICATIONS:
Symptomatic rotator cuff tear, left shoulder.
SUMMARY:
The patient was identified and brought to the operating room, and
placed under general anesthetic. The left shoulder and upper
extremity were prepped and draped in usual sterile fashion with
the arm suspended 10 pounds lateral traction. Arthroscopy has
initiated the standard posterior portal in glenohumeral joint,
and with a lateral portal we were able to debride some of the
undersurface of the rotator cuff. The articular cartilage was
normal. There was bad enough damage to the biceps we felt that
was in need of tenodesis. The labrum was intact. We, therefore,
entered the subacromial space where a thorough subacromial
decompression bursectomy was performed. Following this, we made
an incision through his old scar. Soft tissues dissected down to
the deep fascia. We went ahead and identified the biceps passed
the suture through it and then released it from the superior
labrum. We then inserted 2 bile composite corkscrew anchors on
the medial articular surface for our medial row. We tied the
biceps down and also the rotator cuff, and then tied the sutures,
and then used 12 lock anchors out lateral to get a good solid
double layer repair. We then used the sutures on the swivel
locks to fine tune and tied down a few loose edges of the rotator
cuff repair. Digital palpation showed the decompression was
adequate. After a thorough washout, we closed the deltoid with
some #1 Ethibond sutures, 2-0 Vicryl sutures, and subcutaneous
staples for the skin. We injected some local anesthetic for
postoperative pain control. Sterile dressing was applied with
tape. The patient was transported to recovery room without any
problems.
Need some guidance, pt is 60 years old here is his HPI
below )Would you consider this acute or chronic?
23410 vs 23412
Additionally you cannot code 29826 with 23410 or 23412, so I chose 29822.
I am gathering the biceps tendodesis was done open? 23430 vs arthroscopic 29828?
Thanks Melissa Bedford,CCS,CPC
History of Present Illness
HPI patient presents c/o left shoulder pain. Had been having minor pain, but worsened after pulling object. Since then, has pain using 2 fingers to open a drawer or just reaching out to open the refrigerator
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Arthroscopy of the left shoulder, subacromial decompression.
2. Mini open rotator cuff repair.
3. Biceps tenodesis.
COMPLICATION OF THE PROCEDURE:
None.
SPONGE AND NEEDLE COUNT:
Correct.
DRAIN:
No drain was used.
INDICATIONS:
Symptomatic rotator cuff tear, left shoulder.
SUMMARY:
The patient was identified and brought to the operating room, and
placed under general anesthetic. The left shoulder and upper
extremity were prepped and draped in usual sterile fashion with
the arm suspended 10 pounds lateral traction. Arthroscopy has
initiated the standard posterior portal in glenohumeral joint,
and with a lateral portal we were able to debride some of the
undersurface of the rotator cuff. The articular cartilage was
normal. There was bad enough damage to the biceps we felt that
was in need of tenodesis. The labrum was intact. We, therefore,
entered the subacromial space where a thorough subacromial
decompression bursectomy was performed. Following this, we made
an incision through his old scar. Soft tissues dissected down to
the deep fascia. We went ahead and identified the biceps passed
the suture through it and then released it from the superior
labrum. We then inserted 2 bile composite corkscrew anchors on
the medial articular surface for our medial row. We tied the
biceps down and also the rotator cuff, and then tied the sutures,
and then used 12 lock anchors out lateral to get a good solid
double layer repair. We then used the sutures on the swivel
locks to fine tune and tied down a few loose edges of the rotator
cuff repair. Digital palpation showed the decompression was
adequate. After a thorough washout, we closed the deltoid with
some #1 Ethibond sutures, 2-0 Vicryl sutures, and subcutaneous
staples for the skin. We injected some local anesthetic for
postoperative pain control. Sterile dressing was applied with
tape. The patient was transported to recovery room without any
problems.