khector
New
Hi Coders!
I'm not sure this op report supports billing the unlisted code, but thought I would ask for advice. The surgeon wants to bill 29806 and 29999 with dx 718.81. Does this op report support billing 29806 AND 29999? Thanks!!
PREOPERATIVE DIAGNOSIS:
Left shoulder posterior labral tear.
POSTOPERATIVE DIAGNOSES:
1. Left shoulder posterior labral tear.
2. Posterior capsular tear.
PROCEDURES PERFORMED:
1. Left shoulder arthroscopy posterior labral repair utilizing 3 Gryphon Peek anchors.
2. Posterior capsular repair utilizing a total of 4 free 0 PDS sutures to repair the capsule.
ANESTHESIA:
General with interscalene.
OPERATIVE NARRATIVE:
The patient was seen in the preoperative holding area where his upper extremity was marked. He was then brought back to the operative suite by anesthesia staff where he was laid supine on the operating room table and general anesthesia was induced. I examined his shoulder. He had increased posterior laxity with a significant click with testing versus contralateral arm. At this point, the patient was placed in the La Jolla beach chair position where all bony prominences were padded. Head was placed in neutral. Arm was placed in balanced suspension and kept there through the entirety of the case. The arm was then prepped and draped in usual sterile fashion. Prior to the incision, time-out was taken, same side verification was made and 2 g of Ancef were ordered and given. A standard posterior portal and low and high anterior interval portals established and diagnostic arthroscopy was entertained.
FINDINGS:
The rotator cuff was identified. The anterior, superior, and posterior rotator cuff were pristine. We looked at the labrum. Superiorly, anteriorly, anteroinferiorly everything was intact. There were no obvious capsular rents or injuries in these areas. The biceps tendon was identified as well and found to be stable and without any tearing. The cartilaginous surfaces were also pristine. Switching visualization anteriorly, I noted that there was an obvious tear in the posterior labrum. This posterior labral tear came from about the 7 o'clock position to the 10 o'clock position posterior on the clock face. It was obviously unstable. It was detached. It was non-retracted. However, additionally to this posteriorly there was a significant capsular tear with scarring which was chronic leaving ridiculous capsular laxity over the posterior aspect of the shoulder. This was a secondary problem and made me think that even with repair of the labrum there would still be significant capsule laxity. This was felt to need to be addressed as well.
First we came to the labral repair. We placed cannulas in through all portals. We then freed up the labrum using rasps and elevators. Once this was done, we made a posterolateral portal and placed an anchor at the 7 o'clock, 8 o'clock, and 9 o'clock positions posteriorly. We passed each of the doubly limbed sutures in a horizontal and vertical mattress fashion, thereby doing piece stitch type repair in each of the anchors. We tied these down. This basically shifted the capsule and the labrum back onto the glenoid space. We probed the labrum and found it to be otherwise stable.
We then turned our attention to the repair of the capsule. I used a shaver, as well as an elevator to free up the capsule which was scarred and lax from the undersurface of the infraspinatus tendon and the muscle belly underlying the teres minor. Once this was done, I could pull on the capsule and see where it came together to the other end of the capsule. I used a passer to retrograde and pass a 0-PDS suture through the more medial aspect of the capsule and then re-punctured through the lateral aspect of the capsule and shuttled a PDS suture through this. We did this 4 times from inferior to superior, passing each stitch to reattach the torn medial limb of the capsule to the torn lateral limb of the capsule. Once this was done, we tied each of the sutures very carefully in the subacromial space in order to bring the capsule together. Once this was done, we had a nice capsular repair which reconstituted the tension on the posterior aspect of the shoulder. We then removed all instrumentation from the shoulder, closed all portals with 3-0 nylon suture buried. Sterile dressing was applied. Cold packs were placed over the shoulder. Arm was placed in a mobilizer for mobilization purposes. Patient was then awoken up from anesthesia, transferred to the hospital bed, and transferred to PACU in stable condition. No operative complications at the end of the case. All counts were correct at the end of the case.
I'm not sure this op report supports billing the unlisted code, but thought I would ask for advice. The surgeon wants to bill 29806 and 29999 with dx 718.81. Does this op report support billing 29806 AND 29999? Thanks!!
PREOPERATIVE DIAGNOSIS:
Left shoulder posterior labral tear.
POSTOPERATIVE DIAGNOSES:
1. Left shoulder posterior labral tear.
2. Posterior capsular tear.
PROCEDURES PERFORMED:
1. Left shoulder arthroscopy posterior labral repair utilizing 3 Gryphon Peek anchors.
2. Posterior capsular repair utilizing a total of 4 free 0 PDS sutures to repair the capsule.
ANESTHESIA:
General with interscalene.
OPERATIVE NARRATIVE:
The patient was seen in the preoperative holding area where his upper extremity was marked. He was then brought back to the operative suite by anesthesia staff where he was laid supine on the operating room table and general anesthesia was induced. I examined his shoulder. He had increased posterior laxity with a significant click with testing versus contralateral arm. At this point, the patient was placed in the La Jolla beach chair position where all bony prominences were padded. Head was placed in neutral. Arm was placed in balanced suspension and kept there through the entirety of the case. The arm was then prepped and draped in usual sterile fashion. Prior to the incision, time-out was taken, same side verification was made and 2 g of Ancef were ordered and given. A standard posterior portal and low and high anterior interval portals established and diagnostic arthroscopy was entertained.
FINDINGS:
The rotator cuff was identified. The anterior, superior, and posterior rotator cuff were pristine. We looked at the labrum. Superiorly, anteriorly, anteroinferiorly everything was intact. There were no obvious capsular rents or injuries in these areas. The biceps tendon was identified as well and found to be stable and without any tearing. The cartilaginous surfaces were also pristine. Switching visualization anteriorly, I noted that there was an obvious tear in the posterior labrum. This posterior labral tear came from about the 7 o'clock position to the 10 o'clock position posterior on the clock face. It was obviously unstable. It was detached. It was non-retracted. However, additionally to this posteriorly there was a significant capsular tear with scarring which was chronic leaving ridiculous capsular laxity over the posterior aspect of the shoulder. This was a secondary problem and made me think that even with repair of the labrum there would still be significant capsule laxity. This was felt to need to be addressed as well.
First we came to the labral repair. We placed cannulas in through all portals. We then freed up the labrum using rasps and elevators. Once this was done, we made a posterolateral portal and placed an anchor at the 7 o'clock, 8 o'clock, and 9 o'clock positions posteriorly. We passed each of the doubly limbed sutures in a horizontal and vertical mattress fashion, thereby doing piece stitch type repair in each of the anchors. We tied these down. This basically shifted the capsule and the labrum back onto the glenoid space. We probed the labrum and found it to be otherwise stable.
We then turned our attention to the repair of the capsule. I used a shaver, as well as an elevator to free up the capsule which was scarred and lax from the undersurface of the infraspinatus tendon and the muscle belly underlying the teres minor. Once this was done, I could pull on the capsule and see where it came together to the other end of the capsule. I used a passer to retrograde and pass a 0-PDS suture through the more medial aspect of the capsule and then re-punctured through the lateral aspect of the capsule and shuttled a PDS suture through this. We did this 4 times from inferior to superior, passing each stitch to reattach the torn medial limb of the capsule to the torn lateral limb of the capsule. Once this was done, we tied each of the sutures very carefully in the subacromial space in order to bring the capsule together. Once this was done, we had a nice capsular repair which reconstituted the tension on the posterior aspect of the shoulder. We then removed all instrumentation from the shoulder, closed all portals with 3-0 nylon suture buried. Sterile dressing was applied. Cold packs were placed over the shoulder. Arm was placed in a mobilizer for mobilization purposes. Patient was then awoken up from anesthesia, transferred to the hospital bed, and transferred to PACU in stable condition. No operative complications at the end of the case. All counts were correct at the end of the case.