codedog
True Blue
would this be coded as 29806?,29826, and 29823 ?not sure about 29806
POSTOPERATIVE DIAGNOSES: Right shoulder impingement with perilabral cyst, anterior labral tear, labral fraying of the superior labrum, and partial thickness, rotator cuff tear, supraspinatus tendon 10 to 15%.
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pROCEDURES PERFORMED: Diagnostic right shoulder arthroscopy, arthroscopic
debridement of rotator cuff and labral fraying, and arthroscopic debridement of perilabral cystic lesion and primary repair of anterior labral tear using MicroMax suture anchor and subacromial decompression.
.
PROCEDURE IN DETAIL:
female with persistent right shoulder pain, failed conservative modalities, presented for diagnostic arthroscopy. She had an MRI consistent with perilabral cyst and a probable anterior labral tear. Site was marked. Appropriate antibiotics were given and a scalene block was performed by Anesthesia. She was brought to the operating room and placed in a right lateral decubitus position with right arm retraction and time-out was called. Glenohumeral joint was prepped and draped and landmarks were identified. The glenohumeral joint was injected with 30 cc of sterile normal saline. An arthroscope was inserted into the joint without difficulty. There was noted to be some fraying of the rotator cuff at its insertion site, fraying of the superior labrum. A shaver was placed on the anterior portal and these structures were shaved down. The rotator cuff appeared to have about a 10% thickness of a tear. A biceps labral anchor was stable, but there was a tear extending from the 1:30 to 2 o’clock position on the labrum and it did appear to communicate with the perilabral cyst, which was adjacent to the subscapularis tendon and débrided with a shaver. A rasp was used to prepare the bed. A MicroMax anchor was drilled and placed on the glenoid rim. A suture strand was relayed through the labrum and tied down with a Tennessee slider knot and alternating half hitches with a good quality repair. Suture strands were cut. The subacromial space was entered. A bursectomy was performed. There were no bursal-sided tears. She did have an acromial spur, which was shaved. The CA ligament was recessed and the spur was taken down to a flat acromion with burr performing a decompression. The shoulder was closed with a 4-0 nylon suture, followed by soft dressing and a regular sling. She tolerated the procedure well. All sponge and needle counts were correct at the end of the case, and there were no complications.
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POSTOPERATIVE DIAGNOSES: Right shoulder impingement with perilabral cyst, anterior labral tear, labral fraying of the superior labrum, and partial thickness, rotator cuff tear, supraspinatus tendon 10 to 15%.
.
pROCEDURES PERFORMED: Diagnostic right shoulder arthroscopy, arthroscopic
debridement of rotator cuff and labral fraying, and arthroscopic debridement of perilabral cystic lesion and primary repair of anterior labral tear using MicroMax suture anchor and subacromial decompression.
.
PROCEDURE IN DETAIL:
female with persistent right shoulder pain, failed conservative modalities, presented for diagnostic arthroscopy. She had an MRI consistent with perilabral cyst and a probable anterior labral tear. Site was marked. Appropriate antibiotics were given and a scalene block was performed by Anesthesia. She was brought to the operating room and placed in a right lateral decubitus position with right arm retraction and time-out was called. Glenohumeral joint was prepped and draped and landmarks were identified. The glenohumeral joint was injected with 30 cc of sterile normal saline. An arthroscope was inserted into the joint without difficulty. There was noted to be some fraying of the rotator cuff at its insertion site, fraying of the superior labrum. A shaver was placed on the anterior portal and these structures were shaved down. The rotator cuff appeared to have about a 10% thickness of a tear. A biceps labral anchor was stable, but there was a tear extending from the 1:30 to 2 o’clock position on the labrum and it did appear to communicate with the perilabral cyst, which was adjacent to the subscapularis tendon and débrided with a shaver. A rasp was used to prepare the bed. A MicroMax anchor was drilled and placed on the glenoid rim. A suture strand was relayed through the labrum and tied down with a Tennessee slider knot and alternating half hitches with a good quality repair. Suture strands were cut. The subacromial space was entered. A bursectomy was performed. There were no bursal-sided tears. She did have an acromial spur, which was shaved. The CA ligament was recessed and the spur was taken down to a flat acromion with burr performing a decompression. The shoulder was closed with a 4-0 nylon suture, followed by soft dressing and a regular sling. She tolerated the procedure well. All sponge and needle counts were correct at the end of the case, and there were no complications.
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