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OP note states that an arthrscopic RCR (29827) and SAD(29826+) were performed followed by an open bicep tenodesis (23430). The OP note also states that an open capsular release was performed. I would like to code as 23020, but want to make sure that the OP note supports this.
Here is the portion of the OP note regarding the capsular release:
"I then made a deltopectoral incision over the anterior aspect of the shoulder. Meticulous
hemostasis was achieved. I dissected carefully down to the conjoint tendon. I palpated
the myocutaneous nerve and the axillary nerve. These were then protected for the
remainder of the case. I freed any adhesions underneath the deltoid. Care was taken not to disrupt my rotator cuff tendon repair. Once the deep retractors were placed, I then
looked at the anterior aspect of the shoulder. He had a very thickened clavipectoral
fascia, which could be a response from the injury or could just be chronic. I went ahead
and incised this tissue. I then released the biceps and then identified the stump of the
subscapularis tendon. I placed an Orthocord around it. I then did a capsular release
both anterior and posterior tendon tear. Unfortunately, it was very difficult to mobilize.
I then decided to take down a portion of the conjoint tendon. This allowed for a reflection of the medial aspect and better exposure of the subscapularis. Even with improved exposure, the tendon was not able to be mobilized. I placed a Cobb elevator along the backside of the glenoid neck and then also around the topside as well. Care was taken not to injure the nerves. I then tried to pull laterally and I was able to just achieve the articular margin especially with the arm internally rotated, but there was going to be too much internal rotation to accept the repair. I therefore copiously irrigated. I finished the debridement and then went ahead and tenodesed the biceps. The subscapularis was unrepairable."
Thanks for your help
Here is the portion of the OP note regarding the capsular release:
"I then made a deltopectoral incision over the anterior aspect of the shoulder. Meticulous
hemostasis was achieved. I dissected carefully down to the conjoint tendon. I palpated
the myocutaneous nerve and the axillary nerve. These were then protected for the
remainder of the case. I freed any adhesions underneath the deltoid. Care was taken not to disrupt my rotator cuff tendon repair. Once the deep retractors were placed, I then
looked at the anterior aspect of the shoulder. He had a very thickened clavipectoral
fascia, which could be a response from the injury or could just be chronic. I went ahead
and incised this tissue. I then released the biceps and then identified the stump of the
subscapularis tendon. I placed an Orthocord around it. I then did a capsular release
both anterior and posterior tendon tear. Unfortunately, it was very difficult to mobilize.
I then decided to take down a portion of the conjoint tendon. This allowed for a reflection of the medial aspect and better exposure of the subscapularis. Even with improved exposure, the tendon was not able to be mobilized. I placed a Cobb elevator along the backside of the glenoid neck and then also around the topside as well. Care was taken not to injure the nerves. I then tried to pull laterally and I was able to just achieve the articular margin especially with the arm internally rotated, but there was going to be too much internal rotation to accept the repair. I therefore copiously irrigated. I finished the debridement and then went ahead and tenodesed the biceps. The subscapularis was unrepairable."
Thanks for your help