Hi Everyone,
I am really confused on how to code this one. Any guidance would be appreciated.
PREOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
2. Long head of biceps tendinitis.
3. Shoulder impingement.
4. Acromioclavicular arthritis.
POSTOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
2. Long head of biceps tendinitis.
3. Shoulder impingement.
4. Acromioclavicular arthritis.
OPERATION: Right shoulder scope with synovectomy,
subacromial bursectomy, subacromial
decompression, distal clavicle resection, and
biceps tendon tenodesis.
ANESTHESIA: Interscalene block along with general
anesthesia.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION: The patient tolerated the procedure well. The patient was
admitted to the hospital for observation and pain control.
(patient) who had injured his
shoulder several months ago after falling off a fence. The patient has
initially tried physical therapy and had two injections in the shoulder
without help. The patient was seen in the office and was found to have
somewhat restricted range of motion along with tenderness to palpation
at the long head of the biceps. The patient also had positive speed
test. The patient was scheduled today for shoulder scope with
synovectomy, bursectomy, and possible long head of the biceps tenodesis.
PROCEDURE: The patient was seen in the preoperative area. The patient
was examined. He had tenderness at the acromioclavicular joint. This
was not the case during his examination in the office. The patient was
counseled regarding distal clavicle resection. The patient agreed. The
informed consent was modified to include distal clavicle resection and
manipulation under anesthesia. The patient's surgical mark on each
surgical site was marked. The patient was brought to the operating
room. After induction of general anesthesia, an interscalene block was
administered. After adequate anesthesia was obtained, the patient was
positioned in a beach-chair position. The patient's right upper
extremity was gently manipulated and patient had abduction to about
160 degrees and forward flexion to about 160 degrees. Internal rotation
was measured at 90 degrees. The patient had external rotation to
70 degrees. The patient's right upper extremity was then sterilely
prepped and draped. A sharp No. 11 blade was used to make a posterior
portal to the shoulder in a normal manner. Blunt trocar and cannula
were introduced into the shoulder joint without any difficulty. The
scope was introduced through the shoulder joint, and the shoulder joint
was inspected. There appeared to be a moderate amount of synovitis in
the shoulders, especially in the undersurface of the supraspinatus and
around the labrum. In addition, there was a moderate amount of
synovitis at the insertion of the biceps tendon to the labrum. A spinal
needle was used to locate the anterior portal of the shoulder under
direct visualization from within the shoulder joint. Blunt trocar was
then used to create the portal. A switching stick was used to switch
the metal cannula for a 7-mm cannula. A hooked probe was used
internally, and the labrum was inspected. There appeared to be good
solid circumferential attachment of the labrum. Inspection of the
insertion of the rotator cuff at the footprint revealed a minor amount
of tissue fraying. The VAPR cautery was introduced from the anterior
portal and the synovitis was cauterized. Decision was then made to
tenodese the biceps tendon. Bovie cautery was used to detach the
attachment of the long head of the biceps from the labrum. After
detachment of the biceps, the biceps tendon retracted. The rest of the
shoulder joint was inspected. There were no loose bodies in the
inferior pouch. There were mild degenerative changes at the glenoid
fossa, probably grade II changes. A spinal needle was inserted at the
lateral aspect of the acromion, approximately 1-2 cm distal to the
lateral edge of the acromion. The spinal needle was used to localize
the partial thickness tear of the tendon. PDS suture was inserted
through the spinal needle. The needle was withdrawn, and a suture
grabber was used to grab the suture from the anterior portal. The
posterior cannula was withdrawn and reinserted into the subacromial
space. Inspection of the subacromial space revealed moderate to severe
amount of synovitis. The VAPR cautery was introduced through the
anterior portal, and synovectomy was performed all the way to the
lateral edge of the acromion. The undersurface of the acromion was
cleared using the VAPR. The anterolateral edge was exposed, and the
acromioclavicular joint was also exposed. Next, a 0.5-mm Acromionizer
was introduced from the anterior portal and used to perform a
subacromial decompression. There was no huge anterolateral osteophyte
which needed to be resected. Next, the distal clavicle was resected
using the Acromionizer. We made sure to apply downward pressure on the
clavicle in order to obtain a complete resection of the distal clavicle.
The VAPR was again used to cauterize frayed tissues around the distal
clavicle. The camera was withdrawn and slightly anterior incision was
made starting at the anterolateral edge of the acromion and extending
approximately 1.5 inches distally. The anterior raphe of the deltoid
muscle was exposed, and tissue Freers were used to partition the deltoid
fibers along its length. The bicipital groove was digitally palpated
and a sharp No. 15 scalpel blade was used to make a longitudinal
incision over it. Hemostat was used to retrieve the biceps tendon. A
Mitek suture anchor was placed in the bicipital groove, and the
Orthocord sutures were used to suture the biceps tendon to the adjacent
border of the bicipital groove. The proximal end of the tendon was
folded over the biceps tendon and sutured using the Orthocord sutures.
Normal saline irrigation was applied to the incision. Sutures of
2-0 Vicryl were used to close the deltoid muscle fascia and to close
subcutaneous tissues using interrupted, inverted sutures. Sutures of
5-0 Vicryl were used to close the skin. A spinal needle was introduced
to the glenohumeral joint and an injection of 80 mg methylprednisolone
along with 8 cc of 0.25% Marcaine without epinephrine was injected into
the shoulder joint. The portal sites were closed using 5-0 Vicryl.
Steri-Strips were applied. Sterile dressing was then applied to the
shoulder, and the patient was awakened by the anesthesia staff. In the
postoperative area, the patient had no pain at that time. The patient
had good capillary refill to all of his fingers. The patient will be
admitted for observation and pain control. The patient will be
discharged in the morning.
Thanks for your help
I am really confused on how to code this one. Any guidance would be appreciated.
PREOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
2. Long head of biceps tendinitis.
3. Shoulder impingement.
4. Acromioclavicular arthritis.
POSTOPERATIVE DIAGNOSIS: 1. Right rotator cuff tendinitis.
2. Long head of biceps tendinitis.
3. Shoulder impingement.
4. Acromioclavicular arthritis.
OPERATION: Right shoulder scope with synovectomy,
subacromial bursectomy, subacromial
decompression, distal clavicle resection, and
biceps tendon tenodesis.
ANESTHESIA: Interscalene block along with general
anesthesia.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION: The patient tolerated the procedure well. The patient was
admitted to the hospital for observation and pain control.
(patient) who had injured his
shoulder several months ago after falling off a fence. The patient has
initially tried physical therapy and had two injections in the shoulder
without help. The patient was seen in the office and was found to have
somewhat restricted range of motion along with tenderness to palpation
at the long head of the biceps. The patient also had positive speed
test. The patient was scheduled today for shoulder scope with
synovectomy, bursectomy, and possible long head of the biceps tenodesis.
PROCEDURE: The patient was seen in the preoperative area. The patient
was examined. He had tenderness at the acromioclavicular joint. This
was not the case during his examination in the office. The patient was
counseled regarding distal clavicle resection. The patient agreed. The
informed consent was modified to include distal clavicle resection and
manipulation under anesthesia. The patient's surgical mark on each
surgical site was marked. The patient was brought to the operating
room. After induction of general anesthesia, an interscalene block was
administered. After adequate anesthesia was obtained, the patient was
positioned in a beach-chair position. The patient's right upper
extremity was gently manipulated and patient had abduction to about
160 degrees and forward flexion to about 160 degrees. Internal rotation
was measured at 90 degrees. The patient had external rotation to
70 degrees. The patient's right upper extremity was then sterilely
prepped and draped. A sharp No. 11 blade was used to make a posterior
portal to the shoulder in a normal manner. Blunt trocar and cannula
were introduced into the shoulder joint without any difficulty. The
scope was introduced through the shoulder joint, and the shoulder joint
was inspected. There appeared to be a moderate amount of synovitis in
the shoulders, especially in the undersurface of the supraspinatus and
around the labrum. In addition, there was a moderate amount of
synovitis at the insertion of the biceps tendon to the labrum. A spinal
needle was used to locate the anterior portal of the shoulder under
direct visualization from within the shoulder joint. Blunt trocar was
then used to create the portal. A switching stick was used to switch
the metal cannula for a 7-mm cannula. A hooked probe was used
internally, and the labrum was inspected. There appeared to be good
solid circumferential attachment of the labrum. Inspection of the
insertion of the rotator cuff at the footprint revealed a minor amount
of tissue fraying. The VAPR cautery was introduced from the anterior
portal and the synovitis was cauterized. Decision was then made to
tenodese the biceps tendon. Bovie cautery was used to detach the
attachment of the long head of the biceps from the labrum. After
detachment of the biceps, the biceps tendon retracted. The rest of the
shoulder joint was inspected. There were no loose bodies in the
inferior pouch. There were mild degenerative changes at the glenoid
fossa, probably grade II changes. A spinal needle was inserted at the
lateral aspect of the acromion, approximately 1-2 cm distal to the
lateral edge of the acromion. The spinal needle was used to localize
the partial thickness tear of the tendon. PDS suture was inserted
through the spinal needle. The needle was withdrawn, and a suture
grabber was used to grab the suture from the anterior portal. The
posterior cannula was withdrawn and reinserted into the subacromial
space. Inspection of the subacromial space revealed moderate to severe
amount of synovitis. The VAPR cautery was introduced through the
anterior portal, and synovectomy was performed all the way to the
lateral edge of the acromion. The undersurface of the acromion was
cleared using the VAPR. The anterolateral edge was exposed, and the
acromioclavicular joint was also exposed. Next, a 0.5-mm Acromionizer
was introduced from the anterior portal and used to perform a
subacromial decompression. There was no huge anterolateral osteophyte
which needed to be resected. Next, the distal clavicle was resected
using the Acromionizer. We made sure to apply downward pressure on the
clavicle in order to obtain a complete resection of the distal clavicle.
The VAPR was again used to cauterize frayed tissues around the distal
clavicle. The camera was withdrawn and slightly anterior incision was
made starting at the anterolateral edge of the acromion and extending
approximately 1.5 inches distally. The anterior raphe of the deltoid
muscle was exposed, and tissue Freers were used to partition the deltoid
fibers along its length. The bicipital groove was digitally palpated
and a sharp No. 15 scalpel blade was used to make a longitudinal
incision over it. Hemostat was used to retrieve the biceps tendon. A
Mitek suture anchor was placed in the bicipital groove, and the
Orthocord sutures were used to suture the biceps tendon to the adjacent
border of the bicipital groove. The proximal end of the tendon was
folded over the biceps tendon and sutured using the Orthocord sutures.
Normal saline irrigation was applied to the incision. Sutures of
2-0 Vicryl were used to close the deltoid muscle fascia and to close
subcutaneous tissues using interrupted, inverted sutures. Sutures of
5-0 Vicryl were used to close the skin. A spinal needle was introduced
to the glenohumeral joint and an injection of 80 mg methylprednisolone
along with 8 cc of 0.25% Marcaine without epinephrine was injected into
the shoulder joint. The portal sites were closed using 5-0 Vicryl.
Steri-Strips were applied. Sterile dressing was then applied to the
shoulder, and the patient was awakened by the anesthesia staff. In the
postoperative area, the patient had no pain at that time. The patient
had good capillary refill to all of his fingers. The patient will be
admitted for observation and pain control. The patient will be
discharged in the morning.
Thanks for your help
