Hi list need some of you Ortho experts to weigh in on if I am coding this correctly. I am so confused!
M,,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right shoulder strain, labral tear, bursitis and impingement
syndrome.
POSTOPERATIVE DIAGNOSES:
Right shoulder strain, labral tear, bursitis and impingement
syndrome.
PROCEDURE:
Arthroscopic examination and debridement of labral tear and
subacromial bursa and bony acromioplasty of the right shoulder
with release of the coracoacromial ligament.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 27-year-old white male firefighter who injured his
right shoulder at work several months ago lifting weights. He
had pain and soreness of the shoulder. He has been on therapy
and medication and had injections with persistent pain with
certain movements.
IMAGING:
X-rays and MRI scan showed a type 3 acromion and possible
labral tear and bursitis. Options of continued conservative
care versus surgery were discussed with him at length. He
requests surgical treatment.
PROCEDURE:
After taking informed consent, the patient was brought to the
operating room. He was placed on operating room table in a
supine position. After administration of general LMA
anesthesia, he was placed in the beach chair position. The
right shoulder and arm were sterilely prepped, and draped in a
routine manner.
Time-out was then performed. The patient was identified.
Appropriate body site having been marked. He received
appropriate antibiotics. Next, a posterior arthroscopy portal
was then made and joint subacromial space infiltrated with
saline with epinephrine. Examination under anesthesia showed no instability of the shoulder. The arthroscope was then placed in
the shoulder joint posteriorly and examination was performed.
Examination of the joint showed the rotator cuff to be intact.
The articular surfaces were normal in appearance. There was
some slight fraying of the synovium and there was a tear on
the insight edge of the anterior labrum, but it was noted to be attached to
the glenoid. The biceps tendon was intact and attached to the
Glenoid. There was also some inflammation and fraying of the
posterior labrum and some pinching into the joint
posteriorly. Next, with the aid of Wissinger rod, an anterior
portal was made and a cannula was placed anteriorly. The
biceps tendon was probed again noted to be stable. The labral
injury anteriorly was noted and just some fraying on the
insight edge of the labrum. The posterior labrum also
examined and did not appear to be torn loose. The shoulder
was then manipulated also and noted to be stable. No
instability of the shoulder was noted. Next, with the aid of
shaver, the inflamed synovium and frayed edges of the labrum
was debrided back to stable edges. Remaining portions
shoulder exam was otherwise unremarkable. Next, the
arthroscope was placed back in the posterior portal and
subacromial space and lateral portal was made and a cannula
was placed in the subacromial space laterally. Thickened and
inflamed bursa noted and this was debrided with a shaver. The
rotator cuff was examined superiorly and no tear was noted.
The CA ligament was released with electrocautery. An 18-gauge
spinal needle was used to mark the anterior posterior aspect
of the AC joint and anterolateral acromion. Next, with the
aid of shaver bur and electrocautery, subacromial
decompression was performed. Adequate debridement was done.
Good bony acromioplasty was completed. Remainder of the exam
was otherwise unremarkable. Next, the arthroscopy equipment
was removed from the shoulder. Interrupted Vicryl sutures
used to approximate the subcuticular tissue. Dermabond was
used to seal the skin edges. A sterile dressing was applied.
He was placed in a sling and transferred to recovery in stable
condition. He did receive a block prior to the surgery
M,,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right shoulder strain, labral tear, bursitis and impingement
syndrome.
POSTOPERATIVE DIAGNOSES:
Right shoulder strain, labral tear, bursitis and impingement
syndrome.
PROCEDURE:
Arthroscopic examination and debridement of labral tear and
subacromial bursa and bony acromioplasty of the right shoulder
with release of the coracoacromial ligament.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 27-year-old white male firefighter who injured his
right shoulder at work several months ago lifting weights. He
had pain and soreness of the shoulder. He has been on therapy
and medication and had injections with persistent pain with
certain movements.
IMAGING:
X-rays and MRI scan showed a type 3 acromion and possible
labral tear and bursitis. Options of continued conservative
care versus surgery were discussed with him at length. He
requests surgical treatment.
PROCEDURE:
After taking informed consent, the patient was brought to the
operating room. He was placed on operating room table in a
supine position. After administration of general LMA
anesthesia, he was placed in the beach chair position. The
right shoulder and arm were sterilely prepped, and draped in a
routine manner.
Time-out was then performed. The patient was identified.
Appropriate body site having been marked. He received
appropriate antibiotics. Next, a posterior arthroscopy portal
was then made and joint subacromial space infiltrated with
saline with epinephrine. Examination under anesthesia showed no instability of the shoulder. The arthroscope was then placed in
the shoulder joint posteriorly and examination was performed.
Examination of the joint showed the rotator cuff to be intact.
The articular surfaces were normal in appearance. There was
some slight fraying of the synovium and there was a tear on
the insight edge of the anterior labrum, but it was noted to be attached to
the glenoid. The biceps tendon was intact and attached to the
Glenoid. There was also some inflammation and fraying of the
posterior labrum and some pinching into the joint
posteriorly. Next, with the aid of Wissinger rod, an anterior
portal was made and a cannula was placed anteriorly. The
biceps tendon was probed again noted to be stable. The labral
injury anteriorly was noted and just some fraying on the
insight edge of the labrum. The posterior labrum also
examined and did not appear to be torn loose. The shoulder
was then manipulated also and noted to be stable. No
instability of the shoulder was noted. Next, with the aid of
shaver, the inflamed synovium and frayed edges of the labrum
was debrided back to stable edges. Remaining portions
shoulder exam was otherwise unremarkable. Next, the
arthroscope was placed back in the posterior portal and
subacromial space and lateral portal was made and a cannula
was placed in the subacromial space laterally. Thickened and
inflamed bursa noted and this was debrided with a shaver. The
rotator cuff was examined superiorly and no tear was noted.
The CA ligament was released with electrocautery. An 18-gauge
spinal needle was used to mark the anterior posterior aspect
of the AC joint and anterolateral acromion. Next, with the
aid of shaver bur and electrocautery, subacromial
decompression was performed. Adequate debridement was done.
Good bony acromioplasty was completed. Remainder of the exam
was otherwise unremarkable. Next, the arthroscopy equipment
was removed from the shoulder. Interrupted Vicryl sutures
used to approximate the subcuticular tissue. Dermabond was
used to seal the skin edges. A sterile dressing was applied.
He was placed in a sling and transferred to recovery in stable
condition. He did receive a block prior to the surgery