talitha82
Guest
I am fairly new to shoulder coding, and need an outside opinion on the case below. The doctor thinks he did 29828, 29826, and 29822.
PREOPERATIVE DIAGNOSIS: Impingement syndrome, rotator cuff tear, left shoulder.
POSTOPERATIVE DIAGNOSES: Intraarticular synovitis, impingement syndrome, large rotator cuff tear, left shoulder.
PROCEDURES PERFORMED: Left shoulder arthroscopy, limited intraarticular debridement, subacromial decompression, and repair of a tongue type supraspinatus tear using two side-to-side sutures and two 4.5 HEALIX BR anchors.
INDICATIONS: Please see my dictated history and physical and clinic notes. There has been no change. Review of systems is negative. Risks, benefits, options, prolonged rehabilitation, closure discussed at length. The patient and her husband elected to proceed.
PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After induction of adequate general anesthesia, 1 g of Ancef was given. The patient was carefully placed in the beach chair position with all pressure points padded and the left shoulder was prepped and draped in a sterile manner.
Diagnostic arthroscopy was performed of the left glenohumeral joint. The findings were as follows:
1. Glenohumeral surfaces were normal.
2. Inferior recess and posterior bare areas normal.
3. Anterior capsuloligamentous complex and subscapularis were normal.
4. The biceps tendon was completely normal.
5. The posterior capsuloligamentous complex was normal.
6. There was some synovitis in the anterior and superior aspect of the shoulder.
7. There was a very large retracted rotator cuff tear.
Based on these findings, I debrided the synovitis in the shoulder and removed the arthroscope and placed it in the subacromial space. Likewise, there was a fairly significant amount of bursitis which is debrided.
The rotator cuff tear was studied. The subscapularis was intact. The infraspinatus was intact. The supraspinatus was torn and retracted medially to the level of the glenoid.
Fortunately, I was able to grasp the edge of the free supraspinatus and bring it down to a bleeding bony bed.
Therefore, we fractioned the bone. We then pulled the tendon out to its resting length and placed two side-to-side sutures between the supra and infraspinatus tendons to thereby hold this in place.
Once this was done, one HEALIX 4.5 BR anchor was placed just posterior to the biceps tendon. This was a triple-loaded anchor and three simple sutures were passed in order to repair the posterior aspect of the tear.
This still left a fairly large gap between the leading edge of the supraspinatus and the subscapularis. Even though this was a rotator interval, it was fairly large and it was felt that it was ill advised to leave this in a 46-year-old woman.
Therefore, I placed one anchor just anterior to the biceps tendon and secured the leading edge gently and the third suture was removed.
At this time, the repair was probed and found to be quite stable.
I then took the 3 sutures in the posterior ankle and brought them laterally and impacted them into the greater tuberosity using a PopLok device affecting a double-row repair.
At this point, the arthroscope was inserted into the joint. The repair appeared to be solid. There was no evidence of incarceration of the biceps tendon.
At this point, the arthroscope was removed. Portals closed in standard fashion. Sterile dressing was applied. The patient was awakened and transported to the recovery room in stable condition. There were no complications.
My questions are:
1. Does this look more like a 29827?
2. Where is the documentation to support 29826?
3. In order to code 29822, does he need to be more specific about where exactly in the shoulder he debrided the synovitis, or is this good enough?
PREOPERATIVE DIAGNOSIS: Impingement syndrome, rotator cuff tear, left shoulder.
POSTOPERATIVE DIAGNOSES: Intraarticular synovitis, impingement syndrome, large rotator cuff tear, left shoulder.
PROCEDURES PERFORMED: Left shoulder arthroscopy, limited intraarticular debridement, subacromial decompression, and repair of a tongue type supraspinatus tear using two side-to-side sutures and two 4.5 HEALIX BR anchors.
INDICATIONS: Please see my dictated history and physical and clinic notes. There has been no change. Review of systems is negative. Risks, benefits, options, prolonged rehabilitation, closure discussed at length. The patient and her husband elected to proceed.
PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After induction of adequate general anesthesia, 1 g of Ancef was given. The patient was carefully placed in the beach chair position with all pressure points padded and the left shoulder was prepped and draped in a sterile manner.
Diagnostic arthroscopy was performed of the left glenohumeral joint. The findings were as follows:
1. Glenohumeral surfaces were normal.
2. Inferior recess and posterior bare areas normal.
3. Anterior capsuloligamentous complex and subscapularis were normal.
4. The biceps tendon was completely normal.
5. The posterior capsuloligamentous complex was normal.
6. There was some synovitis in the anterior and superior aspect of the shoulder.
7. There was a very large retracted rotator cuff tear.
Based on these findings, I debrided the synovitis in the shoulder and removed the arthroscope and placed it in the subacromial space. Likewise, there was a fairly significant amount of bursitis which is debrided.
The rotator cuff tear was studied. The subscapularis was intact. The infraspinatus was intact. The supraspinatus was torn and retracted medially to the level of the glenoid.
Fortunately, I was able to grasp the edge of the free supraspinatus and bring it down to a bleeding bony bed.
Therefore, we fractioned the bone. We then pulled the tendon out to its resting length and placed two side-to-side sutures between the supra and infraspinatus tendons to thereby hold this in place.
Once this was done, one HEALIX 4.5 BR anchor was placed just posterior to the biceps tendon. This was a triple-loaded anchor and three simple sutures were passed in order to repair the posterior aspect of the tear.
This still left a fairly large gap between the leading edge of the supraspinatus and the subscapularis. Even though this was a rotator interval, it was fairly large and it was felt that it was ill advised to leave this in a 46-year-old woman.
Therefore, I placed one anchor just anterior to the biceps tendon and secured the leading edge gently and the third suture was removed.
At this time, the repair was probed and found to be quite stable.
I then took the 3 sutures in the posterior ankle and brought them laterally and impacted them into the greater tuberosity using a PopLok device affecting a double-row repair.
At this point, the arthroscope was inserted into the joint. The repair appeared to be solid. There was no evidence of incarceration of the biceps tendon.
At this point, the arthroscope was removed. Portals closed in standard fashion. Sterile dressing was applied. The patient was awakened and transported to the recovery room in stable condition. There were no complications.
My questions are:
1. Does this look more like a 29827?
2. Where is the documentation to support 29826?
3. In order to code 29822, does he need to be more specific about where exactly in the shoulder he debrided the synovitis, or is this good enough?
