coders_rock!
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So far, I've coded it as 29827, 29826, 29825. However, I am not sure about 29825.
How would you code this report? Thank you in advance!
PROCEDURE: Regional anesthesia was induced. The arm was then manipulated under anesthesia with flexion and traction. Audible lysis of adhesions from 140-180 and then externally rotated holding the arm at the side for holding the arm in the supracondylar area, so as to avoid injury to the elbow ligaments. We then brought the arm at 90 degrees of abduction, internal and external rotation, similar lysis of adhesions was identified as well as with adduction. The patient was placed in a beachchair position. The right arm draped and prepped in the usual sterile manner. IV antibiotics were administered. Standard posterior portal was used. Hemostasis was obtained through an anterior portal beneath the biceps tendon. We copiously irrigated this. Obtained hemostasis. We identified a large rotator cuff tear as well as thickening in the rotator interval, for which a capsular release was performed from the anterior portal, we have released the rotator interval and then extended distally anteriorly and inferiorly until we had full release and comparable motion to the opposite side. We copiously irrigated this. Obtained hemostasis. We then brought the arthroscope up into the subacromial space, where we identified significant narrowing for which a decompression was performed from the anterolateral portal using a 6.0 acromionizer from medial to lateral and anterior to posterior. An extensive debridement was performed here after the CA ligament also was released. We then opened the space. There was no further impingement on the cuff. We placed a fourth portal at the anterolateral corner. Through this, we inserted an awl and a tap and inserted two 5.5 bioabsorbable corkscrew anchors with two #2 FiberWires through the islet. Then, in a suture relay fashion from posterior to anterior, we passed all the limbs of the sutures down through the anterior and posterior leaflets of the tendon and then secured this down to bone with Fleega knots in several half hitches. A secure repair was obtained.
How would you code this report? Thank you in advance!
PROCEDURE: Regional anesthesia was induced. The arm was then manipulated under anesthesia with flexion and traction. Audible lysis of adhesions from 140-180 and then externally rotated holding the arm at the side for holding the arm in the supracondylar area, so as to avoid injury to the elbow ligaments. We then brought the arm at 90 degrees of abduction, internal and external rotation, similar lysis of adhesions was identified as well as with adduction. The patient was placed in a beachchair position. The right arm draped and prepped in the usual sterile manner. IV antibiotics were administered. Standard posterior portal was used. Hemostasis was obtained through an anterior portal beneath the biceps tendon. We copiously irrigated this. Obtained hemostasis. We identified a large rotator cuff tear as well as thickening in the rotator interval, for which a capsular release was performed from the anterior portal, we have released the rotator interval and then extended distally anteriorly and inferiorly until we had full release and comparable motion to the opposite side. We copiously irrigated this. Obtained hemostasis. We then brought the arthroscope up into the subacromial space, where we identified significant narrowing for which a decompression was performed from the anterolateral portal using a 6.0 acromionizer from medial to lateral and anterior to posterior. An extensive debridement was performed here after the CA ligament also was released. We then opened the space. There was no further impingement on the cuff. We placed a fourth portal at the anterolateral corner. Through this, we inserted an awl and a tap and inserted two 5.5 bioabsorbable corkscrew anchors with two #2 FiberWires through the islet. Then, in a suture relay fashion from posterior to anterior, we passed all the limbs of the sutures down through the anterior and posterior leaflets of the tendon and then secured this down to bone with Fleega knots in several half hitches. A secure repair was obtained.