vmounce
Guru
Can someone help me with the operative report below? I came up with 29828, 29823, 29826. I am confused on the diagnosis for 29828. Is it done for the SLAP? If so, can I use the 29823 for rotator cuff tear, glenohumeral synovium, anterior labrum? I appreciate the information. Please see below.
Thanks,
Vickie
Post Operative Diagnosis:
Left shoulder SLAP tear
Left glenohumeral synovitis
Left partial rotator cuff tear
Left subacromial bursitis/impingement
Procedures:
1. Left shoulder arthroscopic biceps tenodesis
2. Left arthroscopic limited debridement of undersurface rotator cuff tear, glenohumeral synovium, anterior labrum, rotator interval
3. Left arthroscopic subacromial decompression
Arthroscopic Findings:
There is an effusion in the glenohumeral joint. There is fraying of the anterior labrum. No posterior labral tear identified. There was a SLAP tear with positive liftoff. Partial-thickness rotator cuff tear of the infra and supraspinatus. The glenohumeral joint was injected. There was a hemorrhagic/flamed bursa. Type II acromion identified. No bursal sided rotator cuff tear identified.
Operative Details:
The patient was met in the pre-operative suite where the correct operative site was marked. The patient was brought to the operating room where anesthesia was initiated. The patient was positioned appropriately with all bony prominences well padded. The patient was prepped and draped in the usual sterile fashion and prior to incision a timeout was observed to verify the correct operative site, procedure and antibiotics.
The arthroscope was introduced into a posterior lateral portal. A thorough diagnostic arthroscopy was performed at this time. The findings are noted above.
An anterior portal was created and with a combination of a shaver and electrocautery the undersurface of the rotator cuff, anterior labrum glenohumeral synovium and rotator interval was debrided.
A bird's beak was utilized to place 2 #2 fiber links through the biceps tendon to create 2 luggage tag sutures. These were loaded up to a swivel lock anchor. The biceps was released off the insertion point. The biceps was then placed high in the bicipital groove just above the subscapularis. Excess suture were then cut.
She was then brought to the subacromial space where hemmorrhagic/inflamed bursa was identified. A complete bursectomy was performed. Acromioplasty was completed with an oscillating bur.
All instruments were removed from the shoulder. Portal site were closed with nylon suture. Soft dressing was applied. The patient was placed in a simple sling. Patient was extubated, transferred to hospital bed in the PACU in stable condition. The patient tolerated procedure well without complications.
Thanks,
Vickie
Post Operative Diagnosis:
Left shoulder SLAP tear
Left glenohumeral synovitis
Left partial rotator cuff tear
Left subacromial bursitis/impingement
Procedures:
1. Left shoulder arthroscopic biceps tenodesis
2. Left arthroscopic limited debridement of undersurface rotator cuff tear, glenohumeral synovium, anterior labrum, rotator interval
3. Left arthroscopic subacromial decompression
Arthroscopic Findings:
There is an effusion in the glenohumeral joint. There is fraying of the anterior labrum. No posterior labral tear identified. There was a SLAP tear with positive liftoff. Partial-thickness rotator cuff tear of the infra and supraspinatus. The glenohumeral joint was injected. There was a hemorrhagic/flamed bursa. Type II acromion identified. No bursal sided rotator cuff tear identified.
Operative Details:
The patient was met in the pre-operative suite where the correct operative site was marked. The patient was brought to the operating room where anesthesia was initiated. The patient was positioned appropriately with all bony prominences well padded. The patient was prepped and draped in the usual sterile fashion and prior to incision a timeout was observed to verify the correct operative site, procedure and antibiotics.
The arthroscope was introduced into a posterior lateral portal. A thorough diagnostic arthroscopy was performed at this time. The findings are noted above.
An anterior portal was created and with a combination of a shaver and electrocautery the undersurface of the rotator cuff, anterior labrum glenohumeral synovium and rotator interval was debrided.
A bird's beak was utilized to place 2 #2 fiber links through the biceps tendon to create 2 luggage tag sutures. These were loaded up to a swivel lock anchor. The biceps was released off the insertion point. The biceps was then placed high in the bicipital groove just above the subscapularis. Excess suture were then cut.
She was then brought to the subacromial space where hemmorrhagic/inflamed bursa was identified. A complete bursectomy was performed. Acromioplasty was completed with an oscillating bur.
All instruments were removed from the shoulder. Portal site were closed with nylon suture. Soft dressing was applied. The patient was placed in a simple sling. Patient was extubated, transferred to hospital bed in the PACU in stable condition. The patient tolerated procedure well without complications.
