SLELISON
Guest
I was hoping to get some feedback on the following operative report. I was thinking 23410, 23430, 23120, 29820-59???, 29826 or 29822??? 29820 is bundled into 23410 and 29822. What is the proper way of coding this operative report? Thank you in advance for your time!
PREOPERATIVE DIAGNOSIS:
1. Acute rotator cuff tear.
2. Degenerative arthritis, acromioclavicular joint.
3. Severe biceps tendonitis.
4. Impingement syndrome.
5. Ganglion cyst under subscapularis muscle tendon unit.
POSTOPERATIVE DIAGNOSIS:
1. Acute rotator cuff tear.
2. Degenerative arthritis, acromioclavicular joint.
3. Severe biceps tendonitis.
4. Impingement syndrome.
5. Ganglion cyst under subscapularis muscle tendon unit.
6. Synovitis of the glenohumeral joint.
7. Severe tearing of the long biceps tendon.
PROCEDURE PERFORMED:
1. Left shoulder arthroscopy and limited synovectomy of the glenohumeral joint and debridement of the glenoid labrum near the biceps insertion and release of the long biceps tendon.
2. Arthroscopic subacromial decompression.
3. Open long biceps tenodesis.
4. Open distal clavicle excision.
5. Open repair of supraspinatus tendon tear.
DESCRIPTION OF THE PROCEDURE: The patient was positioned in the beach-chair position and the shoulder was examined under anesthesia with the following findings: normal range of motion, mild crepitation in the acromioclavicular joint region, no glenohumeral instability.
Following this, the shoulder was prepped and draped in the usual sterile fashion. Landmarks about the shoulder were identified. 20 ml of 0.25% Marcaine with epinephrine were injected into the subacromial space in the glenohumeral joint. The portals were made in the standard fashion using the anatomic landmarks. Blunt obturators were used to enter the glenohumeral joint and introduce the scope cannula through the posterior portal. The glenohumeral joint was explored in a systematic fashion with the following findings: there was severe synovitis about the anterior aspect of the glenohumeral joint. There was visible tearing of the long biceps tendon as it entered into the bicipital groove. There was minimal chondromalacia of the glenohumeral joint. There was a flap tear of the glenoid labrum near the insertion of the long biceps tendon. There was a full thickness supraspinatus tear with intact, infraspinatus, terres minor, and subscapularis tendons. The ganglion cyst under the subscapularis tendon was not visible arthroscopically.
An anterior portal was created in the standard fashion in the rotator cuff interval. The suction shaver device was used to remove the synovitis in the anterior shoulder region. Arthroscopic scissors were introduced through the anterior portal and the long biceps tendon was released from its glenoid insertion. The labrum and residual long biceps tendon were smoothed with the arthroscopic suction shaver device.
Next, the subacromial space was entered and subscromial bursectomy and decompression were performed in the standard fashion. The full thickness tear of the supraspinatus tendon was seen and appeared to be reparable. Type I acromion was created in the standard subacromial decompression fashion using the suction shaver device and the arthroscopic bur. The arthroscopic part of the procedure was completed and a curved incision was made over the distal clavicle and down over the deltopectoral region interval. The deltopectoral interval was identified and carefully opened protecting the cephalic vein. The long biceps tendon was identified. There was severe tearing near the insertion. After judging tension and the insertion spot of the tenodesis in the bicipital groove, the torn tendon portion was resected and synovitis around the tendon was removed by scissor dissection. The #2 FiberWire suture was placed in a running locking fashion and the tunnel for the tenodesis was drilled at 7.5 mm and the edges of the tunnel rounded with a rasp. The Biotenodesis screw was attached to the sutures and the tendon was taken into the tunnel to a depth of about 25 mm and the screw advanced having excellent purchase. The sutures were then passed through the tendon and tied further securing the construct. The elbow was taken through full range of motion and tension of the long biceps tendon appeared to be normal. The subscapularis tendon was identified and digital palpation was done under the subscapularis tendon in the region of the cyst seen on the MRI. No palpable cyst was present. It was presumed that it was a ganglion cyst and had decompressed with the digital palpation. Careful search in this region revealed no abnormal findings.
Next, the subcutaneous full thickness flap was elevated and the interval between the medial and middle deltoid was identified and the tendinous raphe split for 4 cm. The supraspinatus tendon was identified. The footprint was prepared using rongeurs and a curet down to bleeding bone. The tendon was mobilized carefully. The tendon quality was good and mobility was good allowing reduction of the tear to the anatomic footprint without undue tension. The tendon was repaired using the FiberTape with the medial row placed first and then the suture strands crossed to the lateral row providing excellent compression of the tendon to the prepared footprint. There were no prominent suture knots and the shoulder was taken through a full range of motion. Anatomic reduction of the repair appeared to be present. It was repaired with the suture bridge technique. The wounds were copiously irrigated on the deltopectoral interval and the deltoid and then these intervals were closed with interrupted 0 Vicryl suture.
Next, the distal clavicle was identified and the fascia was elevated off of the distal 1.5 cm of the clavicle and it was resected with a microsagittal saw. The residual clavicle was rounded with a rongeur and rasp. Findings were consistent with severe degenerative arthritis of the acromioclavicular joint. The remaining clavicle shaft was stable. There was no impingement of the clavicle shaft of the acromion through full range of motion. The wound was copiously irrigated. Hemostasis was obtained with electrocautery and the fascia was closed with interrupted #1 Vicryl suture. The subcutaneous layer was closed with 0 and 2-0 Vicryl suture in all wounds and stapled. Xeroform dressing and abduction sling were placed. The patient was stable throughout the case.
PREOPERATIVE DIAGNOSIS:
1. Acute rotator cuff tear.
2. Degenerative arthritis, acromioclavicular joint.
3. Severe biceps tendonitis.
4. Impingement syndrome.
5. Ganglion cyst under subscapularis muscle tendon unit.
POSTOPERATIVE DIAGNOSIS:
1. Acute rotator cuff tear.
2. Degenerative arthritis, acromioclavicular joint.
3. Severe biceps tendonitis.
4. Impingement syndrome.
5. Ganglion cyst under subscapularis muscle tendon unit.
6. Synovitis of the glenohumeral joint.
7. Severe tearing of the long biceps tendon.
PROCEDURE PERFORMED:
1. Left shoulder arthroscopy and limited synovectomy of the glenohumeral joint and debridement of the glenoid labrum near the biceps insertion and release of the long biceps tendon.
2. Arthroscopic subacromial decompression.
3. Open long biceps tenodesis.
4. Open distal clavicle excision.
5. Open repair of supraspinatus tendon tear.
DESCRIPTION OF THE PROCEDURE: The patient was positioned in the beach-chair position and the shoulder was examined under anesthesia with the following findings: normal range of motion, mild crepitation in the acromioclavicular joint region, no glenohumeral instability.
Following this, the shoulder was prepped and draped in the usual sterile fashion. Landmarks about the shoulder were identified. 20 ml of 0.25% Marcaine with epinephrine were injected into the subacromial space in the glenohumeral joint. The portals were made in the standard fashion using the anatomic landmarks. Blunt obturators were used to enter the glenohumeral joint and introduce the scope cannula through the posterior portal. The glenohumeral joint was explored in a systematic fashion with the following findings: there was severe synovitis about the anterior aspect of the glenohumeral joint. There was visible tearing of the long biceps tendon as it entered into the bicipital groove. There was minimal chondromalacia of the glenohumeral joint. There was a flap tear of the glenoid labrum near the insertion of the long biceps tendon. There was a full thickness supraspinatus tear with intact, infraspinatus, terres minor, and subscapularis tendons. The ganglion cyst under the subscapularis tendon was not visible arthroscopically.
An anterior portal was created in the standard fashion in the rotator cuff interval. The suction shaver device was used to remove the synovitis in the anterior shoulder region. Arthroscopic scissors were introduced through the anterior portal and the long biceps tendon was released from its glenoid insertion. The labrum and residual long biceps tendon were smoothed with the arthroscopic suction shaver device.
Next, the subacromial space was entered and subscromial bursectomy and decompression were performed in the standard fashion. The full thickness tear of the supraspinatus tendon was seen and appeared to be reparable. Type I acromion was created in the standard subacromial decompression fashion using the suction shaver device and the arthroscopic bur. The arthroscopic part of the procedure was completed and a curved incision was made over the distal clavicle and down over the deltopectoral region interval. The deltopectoral interval was identified and carefully opened protecting the cephalic vein. The long biceps tendon was identified. There was severe tearing near the insertion. After judging tension and the insertion spot of the tenodesis in the bicipital groove, the torn tendon portion was resected and synovitis around the tendon was removed by scissor dissection. The #2 FiberWire suture was placed in a running locking fashion and the tunnel for the tenodesis was drilled at 7.5 mm and the edges of the tunnel rounded with a rasp. The Biotenodesis screw was attached to the sutures and the tendon was taken into the tunnel to a depth of about 25 mm and the screw advanced having excellent purchase. The sutures were then passed through the tendon and tied further securing the construct. The elbow was taken through full range of motion and tension of the long biceps tendon appeared to be normal. The subscapularis tendon was identified and digital palpation was done under the subscapularis tendon in the region of the cyst seen on the MRI. No palpable cyst was present. It was presumed that it was a ganglion cyst and had decompressed with the digital palpation. Careful search in this region revealed no abnormal findings.
Next, the subcutaneous full thickness flap was elevated and the interval between the medial and middle deltoid was identified and the tendinous raphe split for 4 cm. The supraspinatus tendon was identified. The footprint was prepared using rongeurs and a curet down to bleeding bone. The tendon was mobilized carefully. The tendon quality was good and mobility was good allowing reduction of the tear to the anatomic footprint without undue tension. The tendon was repaired using the FiberTape with the medial row placed first and then the suture strands crossed to the lateral row providing excellent compression of the tendon to the prepared footprint. There were no prominent suture knots and the shoulder was taken through a full range of motion. Anatomic reduction of the repair appeared to be present. It was repaired with the suture bridge technique. The wounds were copiously irrigated on the deltopectoral interval and the deltoid and then these intervals were closed with interrupted 0 Vicryl suture.
Next, the distal clavicle was identified and the fascia was elevated off of the distal 1.5 cm of the clavicle and it was resected with a microsagittal saw. The residual clavicle was rounded with a rongeur and rasp. Findings were consistent with severe degenerative arthritis of the acromioclavicular joint. The remaining clavicle shaft was stable. There was no impingement of the clavicle shaft of the acromion through full range of motion. The wound was copiously irrigated. Hemostasis was obtained with electrocautery and the fascia was closed with interrupted #1 Vicryl suture. The subcutaneous layer was closed with 0 and 2-0 Vicryl suture in all wounds and stapled. Xeroform dressing and abduction sling were placed. The patient was stable throughout the case.