My doctor wants to bill 29826, 29825, 29820 and 29823 for the following surgery. Please advise if this is correct.
OP Report states:
Next a posterior portal was created for insertion of the arthroscope into the glenohumeral joint. The articular surfaces of the humeral head and glenoid were intact. The biceps tendon was torn with portions of the biceps tendon being fragmented and flipping in between the humeral head and glenoid. The labrum was torn at the anterior and posterior aspects with portions of the torn labrum at these location flipping in between the humeral head and the glenoid. There did not appear to be any areas of labrum detachment. The inferior pouch showed no loose bodies. With shoulder rotation there was no instability.
There was a large amount of thickened and inflamed synovial tissue in both anterior and posterior compartments. In addition, the capsule in the anterior and posterior compartments was scarred with contracture and adhesions.
The undersurface of the rotator cuff showed a tear of the infraspinatus tendon.
An anterior portal was created using the Wissinger rod technique. Through this portal, motorized shaving instruments were used to debride the areas of the torn labrum.
After this was done, the remaining labrum was probed and was intact.
Next, using a motorized shaving instrument, debridement of the torn portion of the proximal biceps tendon was performed.
After this was done, the remaining biceps tendon was probed and was intact with the extent of this partial thickness tear approximately 15% of the overall thickness at this location. The biceps tendon was not unstable.
Next, using a motorized shaving instrument, debridement of the articular surface rotator cuff tear was performed. After this was done, the remaining rotator cuff at this location was probed and was intact with the extent of this partial thickness tear approximately 25% of the overall thickness at this location. The other areas of the articular surface of the rotator cuff were intact.
Next, using a motorized shaving instrument, a partial anterior and partial posterior synovectomy was performed removing the thickened and inflamed synovial tissue in both the anterior and posterior compartments.
Next, the anterior lysis of adhesions and capsular release was performed. This was done using a combination of Bovie cautery and a motorized shaving instrument. This was done starting at the level of the proximal biceps tendon and going distally to the level of the subscapularis tendon. The lower portion of the anterior release was then continued starting at the lower border of the subscapularis tendon and going distally. Care was taken to avoid going too far distally to avoid the area of the axillary nerve.
After this was done, range of motion was checked. The range of motion was improved, but there was still some limitation with forward elevation, cross-chest adduction and internal rotation.
Next, the arthroscope was placed into the anterior portal and the posterior lysis of adhesions and capsular release was performed. This was done using a combination of Bovie cautery and motorized shaving instrument. This was done starting just posterior to the proximal biceps tendon origin and going distally. Care was taken to avoid going too far distally to avoid the area of the axillary nerve.
Next, range of motion was checked. The patient's right shoulder now had restored full range of motion in all directions and equal to his other unaffected shoulder.
The arthroscope was removed from the glenohumeral joint and placed into the subacromial space.
Immediately a significant amount of thickened and inflamed subacromial bursal tissue was seen.
A lateral portal was created for instrumentation into the subacromial space. Through this portal motorized shaving instruments and Bovie cautery was used to perform a subacromial bursectomy. In addition the acromial attachment of the coracoacromial ligament was released.
After this was done the top surface of the rotator cuff was seen to be very inflamed but not torn. The superior surface rotator cuff was probed and there was no further tearing on the superior surface of the rotator cuff. The undersurface of the acromion had a significant type two (2) curve causing obvious impingement on top of the rotator cuff.
Next using motorized Burrs an acromioplasty was performed removing the type two (2) curve and leveling off the remainder of the acromion. After this was done much more space remained above the rotator cuff with no further impingement in this location.
With the arthroscope in place, the shoulder was placed through full forward elevation and full abduction confirming no further impingement in this location.
Following this all-arthroscopic instrumentation was removed. The portals were closed using 4.0 Monocryl in the subcutaneous tissue followed by Steri-Strips and Xeroform followed by sterile compressive dressing. The patient was placed in a sling and changed back to supine position and awoken and extubated and transferred to the recovery room in stable condition.
OP Report states:
Next a posterior portal was created for insertion of the arthroscope into the glenohumeral joint. The articular surfaces of the humeral head and glenoid were intact. The biceps tendon was torn with portions of the biceps tendon being fragmented and flipping in between the humeral head and glenoid. The labrum was torn at the anterior and posterior aspects with portions of the torn labrum at these location flipping in between the humeral head and the glenoid. There did not appear to be any areas of labrum detachment. The inferior pouch showed no loose bodies. With shoulder rotation there was no instability.
There was a large amount of thickened and inflamed synovial tissue in both anterior and posterior compartments. In addition, the capsule in the anterior and posterior compartments was scarred with contracture and adhesions.
The undersurface of the rotator cuff showed a tear of the infraspinatus tendon.
An anterior portal was created using the Wissinger rod technique. Through this portal, motorized shaving instruments were used to debride the areas of the torn labrum.
After this was done, the remaining labrum was probed and was intact.
Next, using a motorized shaving instrument, debridement of the torn portion of the proximal biceps tendon was performed.
After this was done, the remaining biceps tendon was probed and was intact with the extent of this partial thickness tear approximately 15% of the overall thickness at this location. The biceps tendon was not unstable.
Next, using a motorized shaving instrument, debridement of the articular surface rotator cuff tear was performed. After this was done, the remaining rotator cuff at this location was probed and was intact with the extent of this partial thickness tear approximately 25% of the overall thickness at this location. The other areas of the articular surface of the rotator cuff were intact.
Next, using a motorized shaving instrument, a partial anterior and partial posterior synovectomy was performed removing the thickened and inflamed synovial tissue in both the anterior and posterior compartments.
Next, the anterior lysis of adhesions and capsular release was performed. This was done using a combination of Bovie cautery and a motorized shaving instrument. This was done starting at the level of the proximal biceps tendon and going distally to the level of the subscapularis tendon. The lower portion of the anterior release was then continued starting at the lower border of the subscapularis tendon and going distally. Care was taken to avoid going too far distally to avoid the area of the axillary nerve.
After this was done, range of motion was checked. The range of motion was improved, but there was still some limitation with forward elevation, cross-chest adduction and internal rotation.
Next, the arthroscope was placed into the anterior portal and the posterior lysis of adhesions and capsular release was performed. This was done using a combination of Bovie cautery and motorized shaving instrument. This was done starting just posterior to the proximal biceps tendon origin and going distally. Care was taken to avoid going too far distally to avoid the area of the axillary nerve.
Next, range of motion was checked. The patient's right shoulder now had restored full range of motion in all directions and equal to his other unaffected shoulder.
The arthroscope was removed from the glenohumeral joint and placed into the subacromial space.
Immediately a significant amount of thickened and inflamed subacromial bursal tissue was seen.
A lateral portal was created for instrumentation into the subacromial space. Through this portal motorized shaving instruments and Bovie cautery was used to perform a subacromial bursectomy. In addition the acromial attachment of the coracoacromial ligament was released.
After this was done the top surface of the rotator cuff was seen to be very inflamed but not torn. The superior surface rotator cuff was probed and there was no further tearing on the superior surface of the rotator cuff. The undersurface of the acromion had a significant type two (2) curve causing obvious impingement on top of the rotator cuff.
Next using motorized Burrs an acromioplasty was performed removing the type two (2) curve and leveling off the remainder of the acromion. After this was done much more space remained above the rotator cuff with no further impingement in this location.
With the arthroscope in place, the shoulder was placed through full forward elevation and full abduction confirming no further impingement in this location.
Following this all-arthroscopic instrumentation was removed. The portals were closed using 4.0 Monocryl in the subcutaneous tissue followed by Steri-Strips and Xeroform followed by sterile compressive dressing. The patient was placed in a sling and changed back to supine position and awoken and extubated and transferred to the recovery room in stable condition.