Post Op: Left shoulder impingement syndrome refractory to conservative treatment; partial tearing of the anterior labrum; chondromalacia/degenerative changes of the glenohumeral joint.
Procedures Performed: Left shoulder arthroscopy; arthroscopic subacromial decompression; arthroscopic debridement of the anterior labrum; chondroplasty of the glenohumeral joint.
Description: (condensed) The anterior portal was created with localization with a spinal needle. I was able to visualize that this was between the subscapularis tendon and the biceps tendon. The shaver was then placed and extensive debridement of the hypertrophic synovium and partial tearing of hte anterior labrum was performed. The shaver was also used to perform chondroplasty of the humeral articular surface. Essentially, the entire articular surface had fairly significant chondromalacia changes with flaps of cartilage around the periphery. The flaps of cartilage were addressed. There were some at the inferior most aspect of the glenohumeral joint, which were very difficult to get to with the shaver. Further synovium was debrided. The labrum was visualized and that was otherwise intact. The axillary pouch was visualized and no loose bodies were present. The posterior rotator cuff tendon was visualized and that was intact. The biceps tendon was intact. The anchor was stable. The superior rotator cuff tendon was visualized and there was no obvious full-thickness tear present. The work within the shoulder joint was then completed. (He then proceeds to dictate the subacromial decompression)
Can a synovectomy and limited debridement be coded or extensive debridement or just limited debridement? Any thoughts are appreciated!!!
Procedures Performed: Left shoulder arthroscopy; arthroscopic subacromial decompression; arthroscopic debridement of the anterior labrum; chondroplasty of the glenohumeral joint.
Description: (condensed) The anterior portal was created with localization with a spinal needle. I was able to visualize that this was between the subscapularis tendon and the biceps tendon. The shaver was then placed and extensive debridement of the hypertrophic synovium and partial tearing of hte anterior labrum was performed. The shaver was also used to perform chondroplasty of the humeral articular surface. Essentially, the entire articular surface had fairly significant chondromalacia changes with flaps of cartilage around the periphery. The flaps of cartilage were addressed. There were some at the inferior most aspect of the glenohumeral joint, which were very difficult to get to with the shaver. Further synovium was debrided. The labrum was visualized and that was otherwise intact. The axillary pouch was visualized and no loose bodies were present. The posterior rotator cuff tendon was visualized and that was intact. The biceps tendon was intact. The anchor was stable. The superior rotator cuff tendon was visualized and there was no obvious full-thickness tear present. The work within the shoulder joint was then completed. (He then proceeds to dictate the subacromial decompression)
Can a synovectomy and limited debridement be coded or extensive debridement or just limited debridement? Any thoughts are appreciated!!!
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