kellit21
Guru
Hi, I need your opinions on this surgery. The physician states revision of DCR, but I feel maybe we should code more for the scar tissue removal.
DX: Left Shoulder acromiclavicular resection pain status post subacromial decompression, distal clavicle resection, and biceps tenodesis.
Procedure performed: Arthroscopic revision of the distal clavicle resection with removal of scar tissue.
Description in part:
Examination under anesthesia revealed free full range of motion without any evidence of adhesions. He had some popping at the distal clavicle area and crepitus in this area. The labrum was grossly intact with just a little bit of fraying. It was address with a shaver. No adhesions between the acromion and the rotator cuff, but the AC joint, which was identified with a needle, there was extensive scar tissue bridging across the resection site as well as from the undersurface of the clavicle to the rotator cuff. Using an anterior portal and ArthoCare wand, this interval scar tissue was removed and the distal clavicle was revised using bur to smooth down to a nice flat surface. Any undersurface adhesions from the distal clavicle underneath were also removed.
DX: Left Shoulder acromiclavicular resection pain status post subacromial decompression, distal clavicle resection, and biceps tenodesis.
Procedure performed: Arthroscopic revision of the distal clavicle resection with removal of scar tissue.
Description in part:
Examination under anesthesia revealed free full range of motion without any evidence of adhesions. He had some popping at the distal clavicle area and crepitus in this area. The labrum was grossly intact with just a little bit of fraying. It was address with a shaver. No adhesions between the acromion and the rotator cuff, but the AC joint, which was identified with a needle, there was extensive scar tissue bridging across the resection site as well as from the undersurface of the clavicle to the rotator cuff. Using an anterior portal and ArthoCare wand, this interval scar tissue was removed and the distal clavicle was revised using bur to smooth down to a nice flat surface. Any undersurface adhesions from the distal clavicle underneath were also removed.