Please help with the below surgery. I am coding 29823, 29824, and possibly 23430??? We know there is no code for the balloon spacer. I am unsure of what to code for the open biceps exploration/tenodesis.
Procedure Description
51-year-old who had a previous right shoulder massive rotator cuff repair that failed after she fell several weeks after her repair. She presents today for right shoulder arthroscopy, attempted massive rotator cuff repair versus debridement with balloon spacer and open biceps tendon exploration. On the day of operation patient was blocked with a interscalene block on the correct side. Patient was then taken to the operating room where they were placed in the beachchair position the head stabilized in all bony prominences secured and padded. The appropriate arm was cleansed, prepped and draped. Timeout was performed.
Diagnostic shoulder scope:
I Marked the bony contours of the acromion, clavicle, AC joint with the marking pen. I then created a posterior portal by incising the skin using 11 blade and bluntly entered the glenohumeral space. I then inserted the camera posteriorly. Once is able to visualize the biceps tendon appropriate the camera and proceeded with the diagnostic exam. I inserted a spinal needle from the anterior shoulder just lateral to the coracoid process in order to triangulate the positioning for my anterior portal. I then made an incision anteriorly with 11 blade and use a blunt trocar in order to enter the glenohumeral joint from the anterior portal. I then introduced a electrocautery device to perform synovectomy from the inflamed synovium. I also cleaned up the frayed edges of the anterior and SUPERIOR labrum with the electrocautery device as well as the shaver. Diagnostic findings are as detailed below: SLAP tear, Distally placed biceps tendon, AC joint arthropathy, massive irreperatble full-thickness rotator cuff tear, inferior osteophytes in the acromion and clavicle.
SLAP debridement
SLAP tear was noted. This was debrided with electrocautery and shaver.
Subacromial decompression and Distal Clavicle Excision (Arthroscopic):
I then took out the cannulas and inserted the trocar posteriorly to enter the subacromial space. I inserted a electrocautery device in the anterior portal and the subacromial space in order to debride the bursal tissue as well as perform a periosteal dissection of the inferior aspect of the acromion. Lateral incision was made about 1 cm lateral to the edge of the acromion. This incision was transverse. I then
bluntly entered the subacromial space introduced shaver in order to continue shaving the the bursal tissue. I then switch the shaver for a bur. The bur was then used to perform a subacromial decompression in which I shortened the depth of the acromion approximately 5mm. I then took my attention to the AC joint with my camera still on the posterior portal. I placed the bur in the anterior superior portal underneath the acromion and was able to recognize the AC joint. I then took the bur superiorly to shave down the distal edge of the clavicle. I was able to create 7 mm of space between the distal edge of the clavicle and the acromion.
The rotator cuff with known to be irreparable. I debrided the edges of the rotator cuff. I then cleared room for the balloon placement
Balloon Spacer Implantation:
The size of the balloon was first measured by placing a measuring rod on the medial glenoid as the rod came through the lateral portal. A medium balloon was chosen. From the lateral portal I introduced the balloon and placed the inserter a few millimeters medial to the glenoid. I then deployed the balloon and inflated it with normal saline till it was full, then removed 8 cc of saline fluid from the balloon. I then detached the introductory trocar mechanism from the balloon. The balloon remained in the subacromial space in proper position, providing downward force on the humeral head. I was able to move the humeral head in several positions to ensure that the balloon remained in proper location.
Open Exploration of Biceps Tendon:
Incision was made central medially over the proximal humerus measuring about 4 cm. I dissected down with Army-Navy's bluntly. Once at the fascial layer, I was able to break the fascial layer to get to the biceps. I was able to palpate the bulk of the biceps noted to be inferiorly and found the tendon and the musculotendinous junction. I found that the tendon though extended, was still stuck approximately and had difficulty extricating it of the joint. Given that the biceps had very little give in terms of retraction proximally, I decided not to perform full biceps tendon tenodesis, as I was not certain that it would be of substantial benefit. I did, however release the adhesions surrounding the biceps. I washed out the wound and closed it with 2-0 Vicryl.
Thank you all in advance for your help.
Procedure Description
51-year-old who had a previous right shoulder massive rotator cuff repair that failed after she fell several weeks after her repair. She presents today for right shoulder arthroscopy, attempted massive rotator cuff repair versus debridement with balloon spacer and open biceps tendon exploration. On the day of operation patient was blocked with a interscalene block on the correct side. Patient was then taken to the operating room where they were placed in the beachchair position the head stabilized in all bony prominences secured and padded. The appropriate arm was cleansed, prepped and draped. Timeout was performed.
Diagnostic shoulder scope:
I Marked the bony contours of the acromion, clavicle, AC joint with the marking pen. I then created a posterior portal by incising the skin using 11 blade and bluntly entered the glenohumeral space. I then inserted the camera posteriorly. Once is able to visualize the biceps tendon appropriate the camera and proceeded with the diagnostic exam. I inserted a spinal needle from the anterior shoulder just lateral to the coracoid process in order to triangulate the positioning for my anterior portal. I then made an incision anteriorly with 11 blade and use a blunt trocar in order to enter the glenohumeral joint from the anterior portal. I then introduced a electrocautery device to perform synovectomy from the inflamed synovium. I also cleaned up the frayed edges of the anterior and SUPERIOR labrum with the electrocautery device as well as the shaver. Diagnostic findings are as detailed below: SLAP tear, Distally placed biceps tendon, AC joint arthropathy, massive irreperatble full-thickness rotator cuff tear, inferior osteophytes in the acromion and clavicle.
SLAP debridement
SLAP tear was noted. This was debrided with electrocautery and shaver.
Subacromial decompression and Distal Clavicle Excision (Arthroscopic):
I then took out the cannulas and inserted the trocar posteriorly to enter the subacromial space. I inserted a electrocautery device in the anterior portal and the subacromial space in order to debride the bursal tissue as well as perform a periosteal dissection of the inferior aspect of the acromion. Lateral incision was made about 1 cm lateral to the edge of the acromion. This incision was transverse. I then
bluntly entered the subacromial space introduced shaver in order to continue shaving the the bursal tissue. I then switch the shaver for a bur. The bur was then used to perform a subacromial decompression in which I shortened the depth of the acromion approximately 5mm. I then took my attention to the AC joint with my camera still on the posterior portal. I placed the bur in the anterior superior portal underneath the acromion and was able to recognize the AC joint. I then took the bur superiorly to shave down the distal edge of the clavicle. I was able to create 7 mm of space between the distal edge of the clavicle and the acromion.
The rotator cuff with known to be irreparable. I debrided the edges of the rotator cuff. I then cleared room for the balloon placement
Balloon Spacer Implantation:
The size of the balloon was first measured by placing a measuring rod on the medial glenoid as the rod came through the lateral portal. A medium balloon was chosen. From the lateral portal I introduced the balloon and placed the inserter a few millimeters medial to the glenoid. I then deployed the balloon and inflated it with normal saline till it was full, then removed 8 cc of saline fluid from the balloon. I then detached the introductory trocar mechanism from the balloon. The balloon remained in the subacromial space in proper position, providing downward force on the humeral head. I was able to move the humeral head in several positions to ensure that the balloon remained in proper location.
Open Exploration of Biceps Tendon:
Incision was made central medially over the proximal humerus measuring about 4 cm. I dissected down with Army-Navy's bluntly. Once at the fascial layer, I was able to break the fascial layer to get to the biceps. I was able to palpate the bulk of the biceps noted to be inferiorly and found the tendon and the musculotendinous junction. I found that the tendon though extended, was still stuck approximately and had difficulty extricating it of the joint. Given that the biceps had very little give in terms of retraction proximally, I decided not to perform full biceps tendon tenodesis, as I was not certain that it would be of substantial benefit. I did, however release the adhesions surrounding the biceps. I washed out the wound and closed it with 2-0 Vicryl.
Thank you all in advance for your help.