amartinez1
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For some reason I can not grasp the shoulder. Physician did shoulder arthroscopy.He wants me to code for Subacromial Decompression(29826), Synovectomy of Glenohumeral joint(29820), Debridement of the inferior glenoid(29822), Superior Labral anterior Posterior lesion repair(29807)
Findings included significant amount of synovitis in the glenohumeral joint along with arthritic changes in the inferior glenoid and a large anterior superior labral tear. Posterior labrum did not show significant instability. There was some fraying of the labrum without a complete tear. The inferior glenoid also had some fraying of the inferior labrum. Most of the unstable labrum was found anterior superior level toward the mid-glenoid region consistent with a SLAP lesion. Debridement of the labrum was performed as well as using a 4.5 mm shaver. A large cannula was placed anteriorly to allow anterior labral repair. The anterior labrum was captured using a suture shuttle to pass a #2 FiberWire through the anterior labrum and the anterior glenoid was debrided and roughened up at this time and the drill hole was placed in the anterior glenoid at the region of the torn labrum. The #2 FiberWire was threaded through a knotless anchor capturing the anterior labrum the knotless anchor was placed into the predrilled hole to allow fixation of the anterior labrum into the anterior glenoid. Instruments were introduced into the subacromial spae in which a very tight subacromial space was found with significant amount of scar tissue. The acromion was actually bounded down into the rotator cuff muscle to cause significant impingement. There was also impingement from the coracoacromial ligament and this was also resected at this time. Using high speed bur, the downsloping acromion was resected at this time to allow increased base at the subacromial space. the distal clavicle resection was also performed using high-speed bur to allow additional removal of spurring.
I think this should be coded instead for the SLAP repair(29807), Debridement (29822), Subacromial decompression(29826) and resection of the clavicle (29824).
But I am not sure that the op report reflects all of this. Does anyone have any suggestions? or Would you code this differently?
Findings included significant amount of synovitis in the glenohumeral joint along with arthritic changes in the inferior glenoid and a large anterior superior labral tear. Posterior labrum did not show significant instability. There was some fraying of the labrum without a complete tear. The inferior glenoid also had some fraying of the inferior labrum. Most of the unstable labrum was found anterior superior level toward the mid-glenoid region consistent with a SLAP lesion. Debridement of the labrum was performed as well as using a 4.5 mm shaver. A large cannula was placed anteriorly to allow anterior labral repair. The anterior labrum was captured using a suture shuttle to pass a #2 FiberWire through the anterior labrum and the anterior glenoid was debrided and roughened up at this time and the drill hole was placed in the anterior glenoid at the region of the torn labrum. The #2 FiberWire was threaded through a knotless anchor capturing the anterior labrum the knotless anchor was placed into the predrilled hole to allow fixation of the anterior labrum into the anterior glenoid. Instruments were introduced into the subacromial spae in which a very tight subacromial space was found with significant amount of scar tissue. The acromion was actually bounded down into the rotator cuff muscle to cause significant impingement. There was also impingement from the coracoacromial ligament and this was also resected at this time. Using high speed bur, the downsloping acromion was resected at this time to allow increased base at the subacromial space. the distal clavicle resection was also performed using high-speed bur to allow additional removal of spurring.
I think this should be coded instead for the SLAP repair(29807), Debridement (29822), Subacromial decompression(29826) and resection of the clavicle (29824).
But I am not sure that the op report reflects all of this. Does anyone have any suggestions? or Would you code this differently?