evansd
New
Looking for some guidance. The following procedure was coded 29807. Doctor believes this is incorrect and should be 29806. Thoughts?
"...Using a spinal needle I inflated the glenohumeral space using 30mL of normal saline. Using standard surface landmarks, I crated a posterior arthroscopy portal. The arthroscope was introduced in the glenohumeral joint. There was a positive drive-through sign and anteriorly the labrum was noted to be absent along the entire anterior surface of the glenoid. Inferiorly the labrum was present. the posterior labrum was also intact. Anterior portal was created and a cannula was inserted. A prove was introduced in the joint revealing the the posterior labrum was stable to probing. There was a large Hill-Sachs deformity, which appeared to be non-engaging. The rotator cuff was visualized superiorly and note to be intact with no tearing. The biceps tendon was visualized with not intrasubstance tearing or erythema; however, there was a type 2 SLAP tear a the biceps tendon anchor. A tissue elevator was introduced into the joint and the anterior and inferior labrum were elevated off the anterior edge of the glenoid. The camera was then brought through the anterior portal and the anterior glenoid and labrum were inspected. The tissue quality of the anterior labrum was very poor and the capsule was quite patulous. The camera was brought back to the posterior viewing portal. The decision was made to repair the remaining labrum and incorporated capsule for capsule labral repair . Using a suture lasso I began at the inferior 6:30 position and secured a nice portion of capsule and labral complex. The was repaired to the anterior aspect of the glenoid using a pushlock anchor. Three additional anchors were placed in the anterior aspect of the glenoid incorporating both the capsular and labral complex. Lastly, the biceps anchor was secured using a PushLock anchor superior anteriorly on the glenoid. After repair the capsule and labral structures there was no reaming drive-through sign..."
"...Using a spinal needle I inflated the glenohumeral space using 30mL of normal saline. Using standard surface landmarks, I crated a posterior arthroscopy portal. The arthroscope was introduced in the glenohumeral joint. There was a positive drive-through sign and anteriorly the labrum was noted to be absent along the entire anterior surface of the glenoid. Inferiorly the labrum was present. the posterior labrum was also intact. Anterior portal was created and a cannula was inserted. A prove was introduced in the joint revealing the the posterior labrum was stable to probing. There was a large Hill-Sachs deformity, which appeared to be non-engaging. The rotator cuff was visualized superiorly and note to be intact with no tearing. The biceps tendon was visualized with not intrasubstance tearing or erythema; however, there was a type 2 SLAP tear a the biceps tendon anchor. A tissue elevator was introduced into the joint and the anterior and inferior labrum were elevated off the anterior edge of the glenoid. The camera was then brought through the anterior portal and the anterior glenoid and labrum were inspected. The tissue quality of the anterior labrum was very poor and the capsule was quite patulous. The camera was brought back to the posterior viewing portal. The decision was made to repair the remaining labrum and incorporated capsule for capsule labral repair . Using a suture lasso I began at the inferior 6:30 position and secured a nice portion of capsule and labral complex. The was repaired to the anterior aspect of the glenoid using a pushlock anchor. Three additional anchors were placed in the anterior aspect of the glenoid incorporating both the capsular and labral complex. Lastly, the biceps anchor was secured using a PushLock anchor superior anteriorly on the glenoid. After repair the capsule and labral structures there was no reaming drive-through sign..."