marialg888
New
PREOPERATIVE DIAGNOSES: 1. Tear of glenoid labrum. 2. Partial tear rotator cuff. 3. Chronic impingement syndrome, left shoulder.
POSTOPERATIVE DIAGNOSIS: 1. Chronic impingement syndrome, left shoulder.
OPERATIVE PROCEDURES: 1. Diagnostic arthroscopy, left shoulder. 2. Arthroscopic acromioplasty and coplaning of distal clavicle, left shoulder.
INDICATIONS FOR SURGERY: This 33-year-old male presents with a history of pain left shoulder following an MVA on 02/01/2014. The patient complains of pain with elevation and rotation. MRI scan suggested a tear about the anterior superior segments of the labrum and partial-thickness tearing of the articular side of the supraspinatus. Exam was remarkable for tenderness at Codman?s point, pain with elevation of the arm. There is no evidence of glenohumeral instability.
It was felt that the patient is a candidate for diagnostic arthroscopy of the shoulder, possible labral debridement versus repair, possible debridement rotator cuff versus repair with acromioplasty. The proposed surgery, expected outcome, and possible complications including but not limited to infection, bleeding, blood vessel or nerve injury, failure to relieve symptoms, continued shoulder pain, stiffness, weakness, recurrence, need for extended physical therapy, blood vessel or nerve injury have been discussed with the patient. He understood and wished to proceed. Informed consent was obtained.
PROCEDURE IN DETAIL: The patient was interviewed in the preop holding area where the proper surgical site was confirmed with the patient and so marked on the patient. The patient was then brought back to the operating room and placed in the supine position on the OR table where anesthesia was uneventfully administered. The patient was then placed in the modified barber-chair position, properly padded and secured to the table. Evaluation of the left shoulder under anesthesia showed full passive range of motion and no evidence of glenohumeral instability in any plane. The left upper extremity and shoulder girdle were then prepped and draped in sterile fashion. A time out was taken to again confirm the proper surgical site. Arthroscopic portal incisions were established posteriorly and anteriorly. The arthroscope was advanced into the glenohumeral joint via the posterior portal and a probe via the anterior portal. Inspection of the shoulder was carried out demonstrating a normal biceps tendon with a normal biceps labral attachment notable from probing as well as with peel-back test which was negative. The patient had a negative drive-through sign. Articular cartilage of the glenoid and labrum were noted to be normal. There was some proliferative-looking anterior glenoid labral tissue but it did not appear to be torn and there was no instability of the glenoid labrum at any point around the bony labrum. The inferior sulcus was unremarkable. The rotator cuff was noted to be free of any tears. The biceps tendon was pulled into the joint to get greater visualization and no abnormality was noted. The biceps sling was also noted to be intact. No abnormality was encountered.
It was elected to proceed with a subacromial procedure at that point. The arthroscope was advanced into the subacromial space. Inspection of the rotator cuff revealed no bursal-sided tears. It was elected to carry out an acromioplasty. A third anterolateral portal was established through which first the wand was passed. This was utilized to debride soft tissue and to delineate the extent of the acromion and the distal end of the clavicle. Following this, the bur was introduced and acromioplasty was carried out as was coplaning of the distal clavicle. Once it was determined that adequate decompression had been obtained, the bur and arthroscope were switched in their portals and the acromioplasty was completed with some minor additional work done. Copious irrigation was carried out. Instrumentation was removed from the shoulder. Portal incisions were closed with interrupted stitches of nylon suture. A subacromial cortisone injection was carried out. A sterile dressing was applied to the shoulder.
Having tolerated the procedure well, the patient was uneventfully reacted from general anesthesia and brought to PACU in satisfactory condition.
He coded it 29805,29826
Which I am getting denied and no payment on either code.
Can someone please help
POSTOPERATIVE DIAGNOSIS: 1. Chronic impingement syndrome, left shoulder.
OPERATIVE PROCEDURES: 1. Diagnostic arthroscopy, left shoulder. 2. Arthroscopic acromioplasty and coplaning of distal clavicle, left shoulder.
INDICATIONS FOR SURGERY: This 33-year-old male presents with a history of pain left shoulder following an MVA on 02/01/2014. The patient complains of pain with elevation and rotation. MRI scan suggested a tear about the anterior superior segments of the labrum and partial-thickness tearing of the articular side of the supraspinatus. Exam was remarkable for tenderness at Codman?s point, pain with elevation of the arm. There is no evidence of glenohumeral instability.
It was felt that the patient is a candidate for diagnostic arthroscopy of the shoulder, possible labral debridement versus repair, possible debridement rotator cuff versus repair with acromioplasty. The proposed surgery, expected outcome, and possible complications including but not limited to infection, bleeding, blood vessel or nerve injury, failure to relieve symptoms, continued shoulder pain, stiffness, weakness, recurrence, need for extended physical therapy, blood vessel or nerve injury have been discussed with the patient. He understood and wished to proceed. Informed consent was obtained.
PROCEDURE IN DETAIL: The patient was interviewed in the preop holding area where the proper surgical site was confirmed with the patient and so marked on the patient. The patient was then brought back to the operating room and placed in the supine position on the OR table where anesthesia was uneventfully administered. The patient was then placed in the modified barber-chair position, properly padded and secured to the table. Evaluation of the left shoulder under anesthesia showed full passive range of motion and no evidence of glenohumeral instability in any plane. The left upper extremity and shoulder girdle were then prepped and draped in sterile fashion. A time out was taken to again confirm the proper surgical site. Arthroscopic portal incisions were established posteriorly and anteriorly. The arthroscope was advanced into the glenohumeral joint via the posterior portal and a probe via the anterior portal. Inspection of the shoulder was carried out demonstrating a normal biceps tendon with a normal biceps labral attachment notable from probing as well as with peel-back test which was negative. The patient had a negative drive-through sign. Articular cartilage of the glenoid and labrum were noted to be normal. There was some proliferative-looking anterior glenoid labral tissue but it did not appear to be torn and there was no instability of the glenoid labrum at any point around the bony labrum. The inferior sulcus was unremarkable. The rotator cuff was noted to be free of any tears. The biceps tendon was pulled into the joint to get greater visualization and no abnormality was noted. The biceps sling was also noted to be intact. No abnormality was encountered.
It was elected to proceed with a subacromial procedure at that point. The arthroscope was advanced into the subacromial space. Inspection of the rotator cuff revealed no bursal-sided tears. It was elected to carry out an acromioplasty. A third anterolateral portal was established through which first the wand was passed. This was utilized to debride soft tissue and to delineate the extent of the acromion and the distal end of the clavicle. Following this, the bur was introduced and acromioplasty was carried out as was coplaning of the distal clavicle. Once it was determined that adequate decompression had been obtained, the bur and arthroscope were switched in their portals and the acromioplasty was completed with some minor additional work done. Copious irrigation was carried out. Instrumentation was removed from the shoulder. Portal incisions were closed with interrupted stitches of nylon suture. A subacromial cortisone injection was carried out. A sterile dressing was applied to the shoulder.
Having tolerated the procedure well, the patient was uneventfully reacted from general anesthesia and brought to PACU in satisfactory condition.
He coded it 29805,29826
Which I am getting denied and no payment on either code.
Can someone please help