tdesher
Networker
Is there any other code I can use for this procedure? Our IBC contract does not cover 29826 so I cant bill it at all.
PREOPERATIVE DIAGNOSIS: Superior labral tear of the left shoulder.
POSTOPERATIVE DIAGNOSES: Subacromial impingement with bursitis of the left shoulder.
PROCEDURES PERFORMED:
1.Surgical arthroscopy of the left shoulder with subacromial decompression.
2.Bursectomy.
ANESTHESIA: Interscalene block and general.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
OPERATIVE INDICATIONS: The patient is a 45-year-old female with several month history of left shoulder pain after fall at home. She had an MRI of the shoulder which showed the correction of the superior labral tear. She failed nonoperative treatments including anti-inflammatory medication and intraarticular corticosteroid injections. Intraoperatively, there was evidence of sublabral foramen, but no evidence of superior labral tear. There was no evidence of rotator cuff. There was evidence of subacromial impingement and subacromial bursitis.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. The patient was escorted to the operating room, and placed supine on the operating room table. After adequate induction of interscalene and general anesthesia, the left upper extremity was prepped and draped after positioning the patient in beach-chair position. All bony prominences were well-padded. The left upper extremity was prepped and draped in usual sterile fashion. A time-out was performed. Arthroscopic portal sites were infiltrated with 1% lidocaine with epinephrine. A #11 blade was used to establish a posterior portal. The arthroscope was introduced in the glenohumeral joint. The glenohumeral joint showed normal articular cartilage. The biceps tendon was intact. Anterior portal was established with a #11 blade followed by cannula. A probe was introduced. The biceps tendon was probed and found to be firmly attached to the superior labrum. There was no evidence of superior labral tear. There was evidence of sublabral foramen. The rotator cuff was evaluated and was intact without evidence of full-thickness or partial tear. At this time, the arthroscopic instruments were then placed in a subacromial space. A lateral subacromial portal was established. A #11 blade was used to establish the lateral portal. The arthroscopic shaver was introduced. There was marked subacromial bursitis and evidence of subacromial impingement. A subacromial bursectomy was performed with a shaver and an ArthroCare wand. The rotator cuff was visualized from above and found to be intact. An acromioplasty was performed with an oval bur. After adequate acromioplasty and bursectomy was performed, the arm was brought through range of motion there was found no further evidence of impingement. At this time, the shoulder was copiously irrigated. The portals were closed with 3-0 nylon suture in a horizontal fashion. Dressings were Xeroform, 4x4's and Tegaderm. The patient was then placed in a sling and brought to the PACU in stable condition.
All sponge and needle counts were correct on two occasions.
PREOPERATIVE DIAGNOSIS: Superior labral tear of the left shoulder.
POSTOPERATIVE DIAGNOSES: Subacromial impingement with bursitis of the left shoulder.
PROCEDURES PERFORMED:
1.Surgical arthroscopy of the left shoulder with subacromial decompression.
2.Bursectomy.
ANESTHESIA: Interscalene block and general.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
OPERATIVE INDICATIONS: The patient is a 45-year-old female with several month history of left shoulder pain after fall at home. She had an MRI of the shoulder which showed the correction of the superior labral tear. She failed nonoperative treatments including anti-inflammatory medication and intraarticular corticosteroid injections. Intraoperatively, there was evidence of sublabral foramen, but no evidence of superior labral tear. There was no evidence of rotator cuff. There was evidence of subacromial impingement and subacromial bursitis.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. The patient was escorted to the operating room, and placed supine on the operating room table. After adequate induction of interscalene and general anesthesia, the left upper extremity was prepped and draped after positioning the patient in beach-chair position. All bony prominences were well-padded. The left upper extremity was prepped and draped in usual sterile fashion. A time-out was performed. Arthroscopic portal sites were infiltrated with 1% lidocaine with epinephrine. A #11 blade was used to establish a posterior portal. The arthroscope was introduced in the glenohumeral joint. The glenohumeral joint showed normal articular cartilage. The biceps tendon was intact. Anterior portal was established with a #11 blade followed by cannula. A probe was introduced. The biceps tendon was probed and found to be firmly attached to the superior labrum. There was no evidence of superior labral tear. There was evidence of sublabral foramen. The rotator cuff was evaluated and was intact without evidence of full-thickness or partial tear. At this time, the arthroscopic instruments were then placed in a subacromial space. A lateral subacromial portal was established. A #11 blade was used to establish the lateral portal. The arthroscopic shaver was introduced. There was marked subacromial bursitis and evidence of subacromial impingement. A subacromial bursectomy was performed with a shaver and an ArthroCare wand. The rotator cuff was visualized from above and found to be intact. An acromioplasty was performed with an oval bur. After adequate acromioplasty and bursectomy was performed, the arm was brought through range of motion there was found no further evidence of impingement. At this time, the shoulder was copiously irrigated. The portals were closed with 3-0 nylon suture in a horizontal fashion. Dressings were Xeroform, 4x4's and Tegaderm. The patient was then placed in a sling and brought to the PACU in stable condition.
All sponge and needle counts were correct on two occasions.