danielle0419
Networker
I am a new coder to Orthopaedic and I recieved a denial on this operative report.
I used
23430,Lt 726.12
29822,Lt 726.12
29826,Lt 72610
PREOPERATIVE DIAGNOSIS:
Left shoulder impingement syndrome
Left shoulder biceps tendinitis
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
Left shoulder arthroscopic acromioplasty
Left shoulder biceps tenodesis
ANESTHESIA:
General plus preoperative interscalene block
INDICATIONS FOR SURGERY:
Patient has a history of pain in the left shoulder.
Patient injured the left shoulder at work in June 2014 while lifting heavy boxes.
Pain is aggravated with overhead activity. Patient has pain at night.
A MRI obtained on 8/**/14 demonstrated mild bursal sided supraspinatus tendinopathy.
The subscapularis was unremarkable
Biceps tendon demonstrated a longitudinal split tear of the intra-articular segment.
The patient has failed nonoperative care and has failed to obtain satisfactory relief with conservative care. She obtained some relief with a subacromial bursa and injection but obtained
90% relief with a intra-articular injection. However the pain has returned.
Patient therefore elects to proceed with an arthroscopic acromioplasty with a biceps tenodesis if there was evidence of biceps tendinitis or a tear.
Nature the surgery, postoperative course, risks have been reviewed with the patient and their family. They have no questions and agreed to proceed.
OPERATIVE FINDINGS:
Examination under anesthesia revealed full range of motion. There was no evidence of a frozen shoulder. There is no evidence of instability.
Arthroscopic evaluation of the glenohumeral joint demonstrated normal humeral and glenoid articular surfaces.
Superior labrum demonstrated was unremarkable without any evidence of labral tears. Anterior, inferior and posterior labrum were unremarkable.
Biceps tendon showed evidence of tendinitis with significant fraying of the intra-articular portion with a split intra-articular tear.
Subscapularis was normal.
There was no evidence of a tear of the supraspinatus.
The remainder of the rotator cuff was normal.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room.
Anesthesia administered a interscalene block followed by general anesthesia.
Preoperative antibiotics were given.
The patient was positioned in a beachchair position using a Schlein positioner.
The left shoulder was prepped and draped in sterile fashion. Surgical timeout was called.
The arthroscope was introduced through a standard posterior portal. An anterior portal was made using outside-in technique. Arthroscopic evaluation of the glenohumeral joint showed the above noted findings.
The labrum was unremarkable and did not require any debridement.
Biceps tendon demonstrated evidence of tendinitis with fraying. This involved the superior labral attachment. Therefore the ArthroWand was used to release the biceps from the superior labral attachment. This was allowed to retract distally for later mini open tenodesis .
The subscapularis was normal.
The undersurface of the rotator cuff was unremarkable.
Cannulas were now redirected into the subacromial bursa. An additional lateral portal was made. Upon entering the bursa was thickened bursa was debrided using the shaver and the ArthroWand electrocautery.
The bursal surface of the cuff could now be assessed. The bursal surface of the rotator cuff was normal.
Arthroscopic acromioplasty was now carried out. Soft tissue was removed from the undersurface of the acromion. The anterior and lateral margins were defined. AC joint was localized with a spinal needle. Preoperative x-rays had demonstrated a moderate anterior hook of the acromion. This was resected using the arthroscopic bur. With the burr in the lateral portal and the anterior inferior surface of the acromion was resected beginning laterally and extending medially to the AC joint. Several millimeter some bone were resected from the anterior inferior acromion. Arthroscopic viewing and working portals were now reversed. With the bur in the posterior portal. He was converted to a smooth flat surface using a cutting block technique.
The shaver was used to clear the bursa. Bursal surface of the rotator cuff again was assessed. No abnormalities could be visualized. The cannulas were removed. Arthroscopy portals were closed with nylon suture.
Mini open biceps tenodesis was now performed. An incision was made beginning over the anterolateral acromion and extended laterally several centimeters. The deltoid was exposed. This was split in line with its fibers. The deltoid was not detached from the acromion. Retractors were placed exposing the subacromial bursa,the rotator cuff, and the bicipital groove.
The biceps tenodesis was carried out. The bicipital groove was opened exposing the previously released biceps tendon. This again demonstrated moderate tendinitis with a partial tear. A #2 fiber wire whipstitch was placed through the tendon and excess tendon was excised. The tendon was sized to 7 mm. Therefore a 5.5x15 mm Arthrex BioComposite tenodesis screw was selected. A 5 mm socket was in the distal portion of the bicipital groove. The biceps tendon was inserted into the socket tunnel and secured with a 5.5x15 mm tenodesis screw. The attached FiberWire sutures were passed through the adjacent tissue tenodesis. Good repair was obtained.
The rotator cuff could be visualized. The bursal surface was unremarkable.
The wound was now irrigated. Deltoid was repaired using #2 FiberWire force with 2-0 Vicryl suture. Subcutaneous tissue was closed with 2-0 Vicryl and skin was closed with 3-0 Vicryl subcuticular suture with Steri-Strips. Sterile dressing was applied. Patient was placed into a sling.
The patient was awakened from anesthesia and taken to the recovery area in stable condition.
I used
23430,Lt 726.12
29822,Lt 726.12
29826,Lt 72610
PREOPERATIVE DIAGNOSIS:
Left shoulder impingement syndrome
Left shoulder biceps tendinitis
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
Left shoulder arthroscopic acromioplasty
Left shoulder biceps tenodesis
ANESTHESIA:
General plus preoperative interscalene block
INDICATIONS FOR SURGERY:
Patient has a history of pain in the left shoulder.
Patient injured the left shoulder at work in June 2014 while lifting heavy boxes.
Pain is aggravated with overhead activity. Patient has pain at night.
A MRI obtained on 8/**/14 demonstrated mild bursal sided supraspinatus tendinopathy.
The subscapularis was unremarkable
Biceps tendon demonstrated a longitudinal split tear of the intra-articular segment.
The patient has failed nonoperative care and has failed to obtain satisfactory relief with conservative care. She obtained some relief with a subacromial bursa and injection but obtained
90% relief with a intra-articular injection. However the pain has returned.
Patient therefore elects to proceed with an arthroscopic acromioplasty with a biceps tenodesis if there was evidence of biceps tendinitis or a tear.
Nature the surgery, postoperative course, risks have been reviewed with the patient and their family. They have no questions and agreed to proceed.
OPERATIVE FINDINGS:
Examination under anesthesia revealed full range of motion. There was no evidence of a frozen shoulder. There is no evidence of instability.
Arthroscopic evaluation of the glenohumeral joint demonstrated normal humeral and glenoid articular surfaces.
Superior labrum demonstrated was unremarkable without any evidence of labral tears. Anterior, inferior and posterior labrum were unremarkable.
Biceps tendon showed evidence of tendinitis with significant fraying of the intra-articular portion with a split intra-articular tear.
Subscapularis was normal.
There was no evidence of a tear of the supraspinatus.
The remainder of the rotator cuff was normal.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room.
Anesthesia administered a interscalene block followed by general anesthesia.
Preoperative antibiotics were given.
The patient was positioned in a beachchair position using a Schlein positioner.
The left shoulder was prepped and draped in sterile fashion. Surgical timeout was called.
The arthroscope was introduced through a standard posterior portal. An anterior portal was made using outside-in technique. Arthroscopic evaluation of the glenohumeral joint showed the above noted findings.
The labrum was unremarkable and did not require any debridement.
Biceps tendon demonstrated evidence of tendinitis with fraying. This involved the superior labral attachment. Therefore the ArthroWand was used to release the biceps from the superior labral attachment. This was allowed to retract distally for later mini open tenodesis .
The subscapularis was normal.
The undersurface of the rotator cuff was unremarkable.
Cannulas were now redirected into the subacromial bursa. An additional lateral portal was made. Upon entering the bursa was thickened bursa was debrided using the shaver and the ArthroWand electrocautery.
The bursal surface of the cuff could now be assessed. The bursal surface of the rotator cuff was normal.
Arthroscopic acromioplasty was now carried out. Soft tissue was removed from the undersurface of the acromion. The anterior and lateral margins were defined. AC joint was localized with a spinal needle. Preoperative x-rays had demonstrated a moderate anterior hook of the acromion. This was resected using the arthroscopic bur. With the burr in the lateral portal and the anterior inferior surface of the acromion was resected beginning laterally and extending medially to the AC joint. Several millimeter some bone were resected from the anterior inferior acromion. Arthroscopic viewing and working portals were now reversed. With the bur in the posterior portal. He was converted to a smooth flat surface using a cutting block technique.
The shaver was used to clear the bursa. Bursal surface of the rotator cuff again was assessed. No abnormalities could be visualized. The cannulas were removed. Arthroscopy portals were closed with nylon suture.
Mini open biceps tenodesis was now performed. An incision was made beginning over the anterolateral acromion and extended laterally several centimeters. The deltoid was exposed. This was split in line with its fibers. The deltoid was not detached from the acromion. Retractors were placed exposing the subacromial bursa,the rotator cuff, and the bicipital groove.
The biceps tenodesis was carried out. The bicipital groove was opened exposing the previously released biceps tendon. This again demonstrated moderate tendinitis with a partial tear. A #2 fiber wire whipstitch was placed through the tendon and excess tendon was excised. The tendon was sized to 7 mm. Therefore a 5.5x15 mm Arthrex BioComposite tenodesis screw was selected. A 5 mm socket was in the distal portion of the bicipital groove. The biceps tendon was inserted into the socket tunnel and secured with a 5.5x15 mm tenodesis screw. The attached FiberWire sutures were passed through the adjacent tissue tenodesis. Good repair was obtained.
The rotator cuff could be visualized. The bursal surface was unremarkable.
The wound was now irrigated. Deltoid was repaired using #2 FiberWire force with 2-0 Vicryl suture. Subcutaneous tissue was closed with 2-0 Vicryl and skin was closed with 3-0 Vicryl subcuticular suture with Steri-Strips. Sterile dressing was applied. Patient was placed into a sling.
The patient was awakened from anesthesia and taken to the recovery area in stable condition.