trose45116
Expert
I dont think that this is enough to bill the acromioplasty. would you bill 29823 instead.
Impingement syndrome with rotator cuff tear, partial biceps tendon tear.
POSTOPERATIVE DIAGNOSIS: Impingement syndrome with rotator cuff tear, partial biceps tendon tear.
PROCEDURE: 1. Arthroscopic debridement of a labral tear.
2. Arthroscopic acromioplasty.
3. Arthroscopic repair of a grade 2 rotator cuff tear.
ANESTHESIA: General with scalene block for postoperative pain control.
COMPLICATIONS: None.
INDICATIONS: This is a 52-year-old white female with progressive pain and weakness in her left shoulder with night pain. An MRI was consistent with a rotator cuff tear. Intraoperatively, we noted a grade 2 tear which was minimally retracted. Prior to surgery, the possible risks and complications including infection, DVT, pulmonary embolus, recurrent tear, and possible need for further surgery were all explained and she understood and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position. General anesthesia was administered. One gram of Ancef was given preoperatively. The patient was placed on a Tenet frame with a spider. The left shoulder was prepped and draped in sterile fashion.
A posterolateral inflow portal was then established using a 30-degree scope. Diagnostic portion of the exam was carried out intra-articularly with an anterior outflow. Intraoperatively, she was noted to have a biceps tendon tear that was partial. This was debrided using a 4.5 shaver. It appeared to be stable, thus no tenodesis was done. The rotator cuff was noted to be torn with an approximately grade 2 tear about 1 to 2 cm. We went ahead and debrided the edges using a Mitek VAPR and 4.5 shaver. The bleeders were coagulated. An acromioplasty was performed on the anterior rim of the acromion. We then went ahead using Arthrex arthroscopic instruments and made a lateral portal as well as a slightly posterior portal. We went ahead and inserted an anchor with four sutures. We went ahead and passed this using the arthroscopic Scorpion suture passer. We went ahead and tied these down to the bone which was debrided arthroscopically. The tear was noted to be anatomically reduced in good position. No further impingement was noted.
The area was then copiously irrigated with normal saline. Closure was obtained using 4-0 nylon. A bulky dressing was applied. The patient was awakened and taken to recovery room in good condition.
Impingement syndrome with rotator cuff tear, partial biceps tendon tear.
POSTOPERATIVE DIAGNOSIS: Impingement syndrome with rotator cuff tear, partial biceps tendon tear.
PROCEDURE: 1. Arthroscopic debridement of a labral tear.
2. Arthroscopic acromioplasty.
3. Arthroscopic repair of a grade 2 rotator cuff tear.
ANESTHESIA: General with scalene block for postoperative pain control.
COMPLICATIONS: None.
INDICATIONS: This is a 52-year-old white female with progressive pain and weakness in her left shoulder with night pain. An MRI was consistent with a rotator cuff tear. Intraoperatively, we noted a grade 2 tear which was minimally retracted. Prior to surgery, the possible risks and complications including infection, DVT, pulmonary embolus, recurrent tear, and possible need for further surgery were all explained and she understood and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position. General anesthesia was administered. One gram of Ancef was given preoperatively. The patient was placed on a Tenet frame with a spider. The left shoulder was prepped and draped in sterile fashion.
A posterolateral inflow portal was then established using a 30-degree scope. Diagnostic portion of the exam was carried out intra-articularly with an anterior outflow. Intraoperatively, she was noted to have a biceps tendon tear that was partial. This was debrided using a 4.5 shaver. It appeared to be stable, thus no tenodesis was done. The rotator cuff was noted to be torn with an approximately grade 2 tear about 1 to 2 cm. We went ahead and debrided the edges using a Mitek VAPR and 4.5 shaver. The bleeders were coagulated. An acromioplasty was performed on the anterior rim of the acromion. We then went ahead using Arthrex arthroscopic instruments and made a lateral portal as well as a slightly posterior portal. We went ahead and inserted an anchor with four sutures. We went ahead and passed this using the arthroscopic Scorpion suture passer. We went ahead and tied these down to the bone which was debrided arthroscopically. The tear was noted to be anatomically reduced in good position. No further impingement was noted.
The area was then copiously irrigated with normal saline. Closure was obtained using 4-0 nylon. A bulky dressing was applied. The patient was awakened and taken to recovery room in good condition.