joanne71178
Guru
I am having a difficult time interpreting this OP note & want to make sure I am coding this correctly:
23455
23412
23430
Diagnosis codes of 726.10 for the massive rotator cuff repair & tenodesis. 718.01 for the Anterior capsular rupture.
I appreciate any opinions. Thanks in advance!
Post Operative diagnosis: Massive Rotator cuff tear of the supraspinatus and subscapularis tendon with anterior capsular rupture.
Procedure:
1. Repair of arthrotomy and open reapir of subcapular and supraspinatus tendons.
2. Biceps tenodesis.
3. Bankart with capsular shift
'After preparateion and drAing, presentation to the surgical field , and identification with the time out process, an anterior incision was carried trhought the subcutaneous tissue down to the cephalic vein in which the deltoid and pectoral interval was entered. The deltoid vein retracted laterally. The ______ pectoral fascia was then carefully removed and a large comlete tear of the subscapularis tendon identified and appreciated. A portion of the supraspinatus was also torn and the anterior capsule disrupted.
After careful evaluation of the subscapularis tendon, which was retracted approximately 1.5 cm, was retraced medially to identify the capsule separately. This was tied to the glenoid and tot he humerus with one small suture anchor. The subscapulartis tendon and supraspinatus tendons were then carefully repaiared with suture anchors both in the subscapularis tendon and Fiberwire suture in the supraspinatus repairing the tendon. Biceps tenodesis was also perfomred with soft tissue repair with Ethibond. The shoulder was taken through a complete range of motion with fairly forceful external rotatyion with no evidence of any tendon attenuation or repair attenuation. The wound was copiously irrigated with several mL of saline."
23455
23412
23430
Diagnosis codes of 726.10 for the massive rotator cuff repair & tenodesis. 718.01 for the Anterior capsular rupture.
I appreciate any opinions. Thanks in advance!
Post Operative diagnosis: Massive Rotator cuff tear of the supraspinatus and subscapularis tendon with anterior capsular rupture.
Procedure:
1. Repair of arthrotomy and open reapir of subcapular and supraspinatus tendons.
2. Biceps tenodesis.
3. Bankart with capsular shift
'After preparateion and drAing, presentation to the surgical field , and identification with the time out process, an anterior incision was carried trhought the subcutaneous tissue down to the cephalic vein in which the deltoid and pectoral interval was entered. The deltoid vein retracted laterally. The ______ pectoral fascia was then carefully removed and a large comlete tear of the subscapularis tendon identified and appreciated. A portion of the supraspinatus was also torn and the anterior capsule disrupted.
After careful evaluation of the subscapularis tendon, which was retracted approximately 1.5 cm, was retraced medially to identify the capsule separately. This was tied to the glenoid and tot he humerus with one small suture anchor. The subscapulartis tendon and supraspinatus tendons were then carefully repaiared with suture anchors both in the subscapularis tendon and Fiberwire suture in the supraspinatus repairing the tendon. Biceps tenodesis was also perfomred with soft tissue repair with Ethibond. The shoulder was taken through a complete range of motion with fairly forceful external rotatyion with no evidence of any tendon attenuation or repair attenuation. The wound was copiously irrigated with several mL of saline."
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