Would 29806 be the most appropriate code for the following? The physician states subscapularis and rotator interval repairs are intact, and later states rotator interval failure.
A post op office note states “After his shoulder replacement, he regained his range of motion very quickly which makes me believe he probably was pushing it harder than he should have. That probably is why his rotator interval failed.”
PREOPERATIVE DIAGNOSES: Status post right total shoulder replacement, with questionable late rotator cuff failure.
POSTOPERATIVE DIAGNOSES: Right total shoulder replacement, with rotator interval tear.
OPERATIONS PERFORMED: Right shoulder arthroscopy with extensive debridement of scar and rotator interval repair.
INDICATIONS: A 65-year-old active man who is status post anatomic shoulder surfacing. He is initially doing well but has developed some weakness in the shoulder. Examination is suspicious for cuff tear. CT arthrogram was not really diagnostic. He presents for shoulder arthroscopy with possible rotator cuff repair.
DESCRIPTION OF PROCEDURE: He was taken to the OR and placed in the supine position on the operating room table. After administration of anesthesia, he was rolled in the left lateral decubitus position. He was prepped and draped in the usual fashion. After a surgical timeout, a posterior portal was made. The sheath was advanced to the subacromial space over a blunt trocar. It felt into the articular space through the rotator interval. I see the prosthesis clearly. I did extensive scarring. I made a lateral portal and doing a debridement of the scar. I cleaned up the gutters as well as the subacromial space. His subscapularis repair was intact as was the rotator interval repair. I placed 2 side-to-side sutures using the Scorpion, and I had a nice convergence. I then placed a single corkscrew anchor at the bicipital groove. I placed a one limb in the subscapularis and one in the supraspinatus and pulled those together. I initially placed the anchor and had the tangle of the anchor pulled out. I removed the anchor and sutures. I placed new anchor and passed those sutures and had a nice repair. I tightened it up with this another side-to-side Arthro lasso 90 degrees. I was happy with the closure and appeared watertight. There was not a transverse component to the tear with true rotator interval failure. He was closed with nylon. He was dressed with Xeroform, sterile gauze, ABDs, and tape. He was placed in a shoulder immobilizer. He was awakened and taken from the OR in stable condition.
I appreciate any guidance you are able to offer. Thank you.
A post op office note states “After his shoulder replacement, he regained his range of motion very quickly which makes me believe he probably was pushing it harder than he should have. That probably is why his rotator interval failed.”
PREOPERATIVE DIAGNOSES: Status post right total shoulder replacement, with questionable late rotator cuff failure.
POSTOPERATIVE DIAGNOSES: Right total shoulder replacement, with rotator interval tear.
OPERATIONS PERFORMED: Right shoulder arthroscopy with extensive debridement of scar and rotator interval repair.
INDICATIONS: A 65-year-old active man who is status post anatomic shoulder surfacing. He is initially doing well but has developed some weakness in the shoulder. Examination is suspicious for cuff tear. CT arthrogram was not really diagnostic. He presents for shoulder arthroscopy with possible rotator cuff repair.
DESCRIPTION OF PROCEDURE: He was taken to the OR and placed in the supine position on the operating room table. After administration of anesthesia, he was rolled in the left lateral decubitus position. He was prepped and draped in the usual fashion. After a surgical timeout, a posterior portal was made. The sheath was advanced to the subacromial space over a blunt trocar. It felt into the articular space through the rotator interval. I see the prosthesis clearly. I did extensive scarring. I made a lateral portal and doing a debridement of the scar. I cleaned up the gutters as well as the subacromial space. His subscapularis repair was intact as was the rotator interval repair. I placed 2 side-to-side sutures using the Scorpion, and I had a nice convergence. I then placed a single corkscrew anchor at the bicipital groove. I placed a one limb in the subscapularis and one in the supraspinatus and pulled those together. I initially placed the anchor and had the tangle of the anchor pulled out. I removed the anchor and sutures. I placed new anchor and passed those sutures and had a nice repair. I tightened it up with this another side-to-side Arthro lasso 90 degrees. I was happy with the closure and appeared watertight. There was not a transverse component to the tear with true rotator interval failure. He was closed with nylon. He was dressed with Xeroform, sterile gauze, ABDs, and tape. He was placed in a shoulder immobilizer. He was awakened and taken from the OR in stable condition.
I appreciate any guidance you are able to offer. Thank you.