kfrycpc
Guest
We had the following procedure and this is how I coded it. Is this correct? Thanks, K I think I'm unsure of the 59 mod than anything else.
PROCEDURES PERFORMED:
1. Left arthroscopic distal clavicle excision, 29824.
2. Left arthroscopic subacromial decompression, 29826-59.
3. Left arthroscopic rotator cuff debridement extensive, 29823-59.
OPERATIVE PROCEDURE: An intravenous antibiotic was administered in the holding area. The patient was brought to the operating room. After the administration of general anesthesia, a time-out was performed and the correct operative extremity was confirmed with the OR team. The patient was placed in the lateral decubitus position with 15 pounds of distal traction applied to the operative extremity. The operative shoulder was prepped and draped in a standard sterile fashion.
For hemostasis and postoperative analgesia, standard shoulder arthroscopic portals as well as the subacromial space and acromioclavicular joint were infiltrated with 30 mL of 0.5% Marcaine with epinephrine.
First, the glenohumeral joint was inspected. There was appreciated to be a partial-thickness tear of the rotator cuff. There was appreciated to be less than 50% of the thickness of the supraspinatus. The biceps was appreciated to be intact. The glenohumeral joint was appreciated to be in good condition. The subscapularis was appreciated to be intact. From an anterior working portal, the undersurface of the supraspinatus was carefully debrided using a shaver. A thorough and extensive rotator cuff debridement had been performed. The labrum was appreciated to be intact.
Next, attention was directed to the subacromial space. The undersurface of the coracoacromial ligament was noted to have significant fraying. There was noted to be significant subacromial bursitis. From a lateral working portal, a thorough bursectomy was performed using a shaver. The undersurface of the anterolateral acromion was debrided of soft tissue using the shaver and bipolar electrocautery. A significant subacromial spur was appreciated.
The acromioclavicular joint was appreciated to have significant degenerative changes. The AC joint was debrided of soft tissue using the shaver and bipolar wand.
Now the camera was switched to the lateral position. The rotator cuff was visualized and noted to be intact. From a posterior working portal, the acromion was smoothed and converted to a type I acromion using a bur. A thorough arthroscopic subacromial decompression had been performed.
Now from an anterior working portal, the AC joint was further exposed. A bur was used to perform a smooth resection of 1.2 cm of distal clavicle. Hemostasis was achieved with the bipolar electrocautery. The end of the resected distal clavicle was readily visualized from the lateral viewing portal. A complete arthroscopic distal clavicle resection had been performed.
The shoulder joint and subacromial space were drained. Portal sites were closed using interrupted Prolene suture. A sterile dressing and a Cryo/Cuff were applied. The patient was awakened from anesthesia and brought to the recovery room in stable condition.
PROCEDURES PERFORMED:
1. Left arthroscopic distal clavicle excision, 29824.
2. Left arthroscopic subacromial decompression, 29826-59.
3. Left arthroscopic rotator cuff debridement extensive, 29823-59.
OPERATIVE PROCEDURE: An intravenous antibiotic was administered in the holding area. The patient was brought to the operating room. After the administration of general anesthesia, a time-out was performed and the correct operative extremity was confirmed with the OR team. The patient was placed in the lateral decubitus position with 15 pounds of distal traction applied to the operative extremity. The operative shoulder was prepped and draped in a standard sterile fashion.
For hemostasis and postoperative analgesia, standard shoulder arthroscopic portals as well as the subacromial space and acromioclavicular joint were infiltrated with 30 mL of 0.5% Marcaine with epinephrine.
First, the glenohumeral joint was inspected. There was appreciated to be a partial-thickness tear of the rotator cuff. There was appreciated to be less than 50% of the thickness of the supraspinatus. The biceps was appreciated to be intact. The glenohumeral joint was appreciated to be in good condition. The subscapularis was appreciated to be intact. From an anterior working portal, the undersurface of the supraspinatus was carefully debrided using a shaver. A thorough and extensive rotator cuff debridement had been performed. The labrum was appreciated to be intact.
Next, attention was directed to the subacromial space. The undersurface of the coracoacromial ligament was noted to have significant fraying. There was noted to be significant subacromial bursitis. From a lateral working portal, a thorough bursectomy was performed using a shaver. The undersurface of the anterolateral acromion was debrided of soft tissue using the shaver and bipolar electrocautery. A significant subacromial spur was appreciated.
The acromioclavicular joint was appreciated to have significant degenerative changes. The AC joint was debrided of soft tissue using the shaver and bipolar wand.
Now the camera was switched to the lateral position. The rotator cuff was visualized and noted to be intact. From a posterior working portal, the acromion was smoothed and converted to a type I acromion using a bur. A thorough arthroscopic subacromial decompression had been performed.
Now from an anterior working portal, the AC joint was further exposed. A bur was used to perform a smooth resection of 1.2 cm of distal clavicle. Hemostasis was achieved with the bipolar electrocautery. The end of the resected distal clavicle was readily visualized from the lateral viewing portal. A complete arthroscopic distal clavicle resection had been performed.
The shoulder joint and subacromial space were drained. Portal sites were closed using interrupted Prolene suture. A sterile dressing and a Cryo/Cuff were applied. The patient was awakened from anesthesia and brought to the recovery room in stable condition.