dyoungberg
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Dr performed arthroscopic repair of the supraspinatus & subscaplaris tendons using separate portals. I'm billing for the ASC. What is the correct way to code these 2 procedures? Op notes are listed below.
Thanks very much!
Prominent subacromial bone was seen to be impinging upon the rotator cuff in the area of the what looked to be a near complete tear of the rotator cuff supraspinatus, extending 1.5 cm from anterior to posterior with just a thin veil of tissue that was keeping it from being a complete tear. That tissue was cut using cautery device to complete the tear and this was debrided and repaired using arthroscopic technique. An accessory “anchor portal” was utilized, developed using needle localization technique just off the lateral edge of the acromion to place a suture anchor at a “dead man's angle” or 45 degree angle to the bone to repair this tear. The anchor was inserted at the articular cartilage margin after debriding using full radius resector and cautery device to lightly abrade that surface to prepare the bone for tendon healing purposes. Once the suture anchor screw was inserted, marrow vents were placed as described below and the attached #2 FiberWire was then passed using the appropriate suturing device. Two of the three attached sutures were all that were required and the third suture was removed since an anatomic and watertight repair was achieved with two sutures passed in a simple suturing technique to perform single row repair. Once all sutures were passed, they were tied using six alternating half hitches, switching posts between the third and fourth half hitch.
Subscapularis was torn and retracted from the lesser tuberosity with small remnant of intact subscapularis tendon seen to be attached which allowed grasping of the tendon medially and retracting for repair which was accomplished using all arthroscopic technique. This was a separate repair from the repair of the rotator cuff supraspinatus portion that was accomplished within the bursal space. The repair of the subscapularis tendon was all done within the joint and required special portals and instrumentation to accomplish this. A portal was developed that allowed passage of the Spectrum suture device and placement of an anchor to secure sutures into the lesser tuberosity. Once the portal was developed, the area of the lesser tuberosity was abraded of soft tissue and lightly decorticated using a bur to get bleeding surface for healing of soft tissue through a healing response. The subscapularis tendon was then sutured by passage of #1 PDS ligature through the tendon as it was retracted, and the suture was then retrieved through the lateral portal. The suture was utilized as a shuttle type suture to allow passage of #2 FiberWire. The first suture then served as a traction stitch and allowed passage of another suture more medial to that one. Gentle retraction was done and appeared to allow for excellent anatomic repair of the tendon, and this was then secured by placing a single Arthrex 4.5 mm PushLock suture anchor through a punch hole. Sutures were placed in the anchor and driven into the prepunched hole with excellent fixation of the tendon back to the bone achieved.
Note that this repair was completely separate from the repair done through the bursa through separate portals required to repair the supraspinatus rotator cuff tendon tear. This repair of the subscapularis tendon required separate portals and instrumentation in order to repair this tendon tear through the glenohumeral joint and was able to be done in avoidance an additional open procedure to this patient's shoulder. [/I][/I][/B][/COLOR]
Thanks very much!
Prominent subacromial bone was seen to be impinging upon the rotator cuff in the area of the what looked to be a near complete tear of the rotator cuff supraspinatus, extending 1.5 cm from anterior to posterior with just a thin veil of tissue that was keeping it from being a complete tear. That tissue was cut using cautery device to complete the tear and this was debrided and repaired using arthroscopic technique. An accessory “anchor portal” was utilized, developed using needle localization technique just off the lateral edge of the acromion to place a suture anchor at a “dead man's angle” or 45 degree angle to the bone to repair this tear. The anchor was inserted at the articular cartilage margin after debriding using full radius resector and cautery device to lightly abrade that surface to prepare the bone for tendon healing purposes. Once the suture anchor screw was inserted, marrow vents were placed as described below and the attached #2 FiberWire was then passed using the appropriate suturing device. Two of the three attached sutures were all that were required and the third suture was removed since an anatomic and watertight repair was achieved with two sutures passed in a simple suturing technique to perform single row repair. Once all sutures were passed, they were tied using six alternating half hitches, switching posts between the third and fourth half hitch.
Subscapularis was torn and retracted from the lesser tuberosity with small remnant of intact subscapularis tendon seen to be attached which allowed grasping of the tendon medially and retracting for repair which was accomplished using all arthroscopic technique. This was a separate repair from the repair of the rotator cuff supraspinatus portion that was accomplished within the bursal space. The repair of the subscapularis tendon was all done within the joint and required special portals and instrumentation to accomplish this. A portal was developed that allowed passage of the Spectrum suture device and placement of an anchor to secure sutures into the lesser tuberosity. Once the portal was developed, the area of the lesser tuberosity was abraded of soft tissue and lightly decorticated using a bur to get bleeding surface for healing of soft tissue through a healing response. The subscapularis tendon was then sutured by passage of #1 PDS ligature through the tendon as it was retracted, and the suture was then retrieved through the lateral portal. The suture was utilized as a shuttle type suture to allow passage of #2 FiberWire. The first suture then served as a traction stitch and allowed passage of another suture more medial to that one. Gentle retraction was done and appeared to allow for excellent anatomic repair of the tendon, and this was then secured by placing a single Arthrex 4.5 mm PushLock suture anchor through a punch hole. Sutures were placed in the anchor and driven into the prepunched hole with excellent fixation of the tendon back to the bone achieved.
Note that this repair was completely separate from the repair done through the bursa through separate portals required to repair the supraspinatus rotator cuff tendon tear. This repair of the subscapularis tendon required separate portals and instrumentation in order to repair this tendon tear through the glenohumeral joint and was able to be done in avoidance an additional open procedure to this patient's shoulder. [/I][/I][/B][/COLOR]
