Hey coders! I desperately need help coding this op note...I am just don't know how to precede. I am thinking 29999 and compare it to 27062. The physician coded 29862 & 29999 but I am not seeing the debridement. Any help will be greatly appreciated. This is the op note:
POSTOPERATIVE DIAGNOSES: Right refractory trochanteric bursitis with possible partial-thickness
tearing of the abductor tendon, no full-thickness abductor tendon tearing visualized.
PROCEDURES PERFORMED: Right hip endoscopic trochanteric bursectomy, IT band lengthening
and three gluteal debridement
I was able to easily palpate the most superficial portion of
the greater trochanter. I marked that and I went a hand breadth proximal and distal. I then removed the
areas of adhesions with the superficial to the bursa with a trocar. I inserted a spinal needle to mark the
central portion of the greater trochanter. I turned my water on at 40 degrees of pressure mmHg. I then
inserted a shaver. I debrided the adhesions that were through the subcutaneous tissue and IT band. Once
this was adequately exposed with a shaver both anteriorly and posteriorly, I palpated with the spinal needle
to central aspect and then I switched back-and-forth between the superior and inferior portal sites and
then palpated the spinal needle and palpated the anterior and posterior aspect and then centrally I went
through the IT band with electrocautery and then went both inferior and superior to expose the entirety of
the trochanteric bursa. I used the vastus lateralis of my landmark for how deep I needed to be. I then
debrided the bone amount of hemorrhagic bursa with mixing back with shaver and electrocautery to obtain
hemostasis. Following this, I internally and externally rotated the hip. There were some superficial
abrasions at the most superficial aspect of the greater trochanter. I lightly debrided that. There was no
structural integrity that was lost with the partial tearing. There was no palpable defects within the tissue
that was attaching at the greater trochanter. At that time, I elected to simply do no repair. I then put the
water out, obtained hemostasis with the water out and then closed with 3-0 nylon. I inserted 30 cc of
0.5% Marcaine. The patient was successfully awoken up from anesthesia. He was placed in a brace
from 0 to 90 and the patient was taken to PACU in stable condition and was discharged home
POSTOPERATIVE DIAGNOSES: Right refractory trochanteric bursitis with possible partial-thickness
tearing of the abductor tendon, no full-thickness abductor tendon tearing visualized.
PROCEDURES PERFORMED: Right hip endoscopic trochanteric bursectomy, IT band lengthening
and three gluteal debridement
I was able to easily palpate the most superficial portion of
the greater trochanter. I marked that and I went a hand breadth proximal and distal. I then removed the
areas of adhesions with the superficial to the bursa with a trocar. I inserted a spinal needle to mark the
central portion of the greater trochanter. I turned my water on at 40 degrees of pressure mmHg. I then
inserted a shaver. I debrided the adhesions that were through the subcutaneous tissue and IT band. Once
this was adequately exposed with a shaver both anteriorly and posteriorly, I palpated with the spinal needle
to central aspect and then I switched back-and-forth between the superior and inferior portal sites and
then palpated the spinal needle and palpated the anterior and posterior aspect and then centrally I went
through the IT band with electrocautery and then went both inferior and superior to expose the entirety of
the trochanteric bursa. I used the vastus lateralis of my landmark for how deep I needed to be. I then
debrided the bone amount of hemorrhagic bursa with mixing back with shaver and electrocautery to obtain
hemostasis. Following this, I internally and externally rotated the hip. There were some superficial
abrasions at the most superficial aspect of the greater trochanter. I lightly debrided that. There was no
structural integrity that was lost with the partial tearing. There was no palpable defects within the tissue
that was attaching at the greater trochanter. At that time, I elected to simply do no repair. I then put the
water out, obtained hemostasis with the water out and then closed with 3-0 nylon. I inserted 30 cc of
0.5% Marcaine. The patient was successfully awoken up from anesthesia. He was placed in a brace
from 0 to 90 and the patient was taken to PACU in stable condition and was discharged home