Desperate Denise
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I am really having a hard time with shoulder surgery coding - please help.
My question once again is about arthroscopic shoulder procedures performed with open shoulder procedures. In this case the physician performed arthroscopically a repair of a complex labral tear and an extensive debridement of the glenohumeral joint. Then he performs an open biceps tenodesis. Please let me know what you guys think.
POSTOPERATIVE DIAGNOSIS:
1. Right shoulder pain.
2. Right shoulder instability.
3. Right shoulder anterior labral tear.
4. Right shoulder complex type IV superior labrum anterior and
posterior lesion.
OPERATION PERFORMED:
1. Right shoulder arthroscopy.
2. Right shoulder anterior labral repair.
3. Right shoulder biceps tenodesis.
4. Right shoulder extensive debridement of glenohumeral joint.
The bony landmarks of the shoulder, including posterior
lateral, lateral and anterior lateral aspects of the acromion, were marked
with a marking pen. The AC joint and coracoid process were marked with a
marking pen. The mark was made 2 fingerbreadths down, 2 fingerbreadths
medial from the posterior and lateral aspect of the acromion. An 18 gauge
spinal needle was inserted into the glenohumeral joint. The joint was
distended with 60 mL of sterile saline. An 11 blade scalpel was used to
incise the skin. The arthroscope was introduced into the glenohumeral
joint, and the diagnostic arthroscopy was begun. There was evidence of
grade I-II chondromalacial changes over the humeral head, minimal
chondromalacial changes over the glenoid surface. There was evidence of
an anterior labral tear with a bony Bankart. There was evidence of a type
IV SLAP lesion. There was no evidence of a rotator cuff tendon tearing.
No evidence of loose bodies within the axillary pouch. An anterior portal
was established using an outside-in technique. An 18 gauge spinal needle
was inserted above the superior border of the subscapularis muscle. An 11
blade scalpel was used to incise the skin. A 7.0 cannula from Arthrex was
introduced into the glenohumeral joint. The labrum was felt to be
unstable and of poor tissue quality and unrepairable. The superior labrum
was debrided. The biceps tendon had partial tearing along its root. The
biceps tendon was tenotomized. Attention was then turned to the anterior
labrum. The small bony Bankart piece was removed. The anterior neck of
the glenoid was cleared of all soft tissue and decorticated using a 4.0
acromionizer bur. The anterior labrum was mobilized using a periosteal
elevator. Then 4 Griffin anchors were placed on the anterior face of the
glenoid, and these were then passed using a 45 degree suture lasso to the
right. These were tied in a sequential fashion starting from anterior-
inferior to anterior-superior. Once the labral repair was complete,
arthroscopic probe was used to probe the repair and it was felt to be
stable. All the labral repair was complete, all arthroscopic
instrumentation was removed from the shoulder. A 3 cm incision was made
over the anterior lateral aspect of the shoulder. The raphe between the
anterior and medial heads of the deltoid was identified. Blunt dissection
was carried down to identify the intertubercular groove. The sheath
overlying the intertubercular groove was incised with electrocautery.
Biceps tendon was exposed. A single 5.5 Healix anchor was placed in the
intertubercular groove after it was decorticated. The limbs of the 5.5
Healix anchor were threaded in a locking stitch configuration to the
biceps tendon. The biceps tendon was secured within the intertubercular
groove. Copious irrigation was performed. The sheath overlying the
intertubercular groove was closed with 2-0 Vicryl in an interrupted
fashion. Deltoid fascia was closed with 2-0 Vicryl in an interrupted
fashion.
Thank you guys in advance - I don't know what I would do without you!!!
Denise
My question once again is about arthroscopic shoulder procedures performed with open shoulder procedures. In this case the physician performed arthroscopically a repair of a complex labral tear and an extensive debridement of the glenohumeral joint. Then he performs an open biceps tenodesis. Please let me know what you guys think.
POSTOPERATIVE DIAGNOSIS:
1. Right shoulder pain.
2. Right shoulder instability.
3. Right shoulder anterior labral tear.
4. Right shoulder complex type IV superior labrum anterior and
posterior lesion.
OPERATION PERFORMED:
1. Right shoulder arthroscopy.
2. Right shoulder anterior labral repair.
3. Right shoulder biceps tenodesis.
4. Right shoulder extensive debridement of glenohumeral joint.
The bony landmarks of the shoulder, including posterior
lateral, lateral and anterior lateral aspects of the acromion, were marked
with a marking pen. The AC joint and coracoid process were marked with a
marking pen. The mark was made 2 fingerbreadths down, 2 fingerbreadths
medial from the posterior and lateral aspect of the acromion. An 18 gauge
spinal needle was inserted into the glenohumeral joint. The joint was
distended with 60 mL of sterile saline. An 11 blade scalpel was used to
incise the skin. The arthroscope was introduced into the glenohumeral
joint, and the diagnostic arthroscopy was begun. There was evidence of
grade I-II chondromalacial changes over the humeral head, minimal
chondromalacial changes over the glenoid surface. There was evidence of
an anterior labral tear with a bony Bankart. There was evidence of a type
IV SLAP lesion. There was no evidence of a rotator cuff tendon tearing.
No evidence of loose bodies within the axillary pouch. An anterior portal
was established using an outside-in technique. An 18 gauge spinal needle
was inserted above the superior border of the subscapularis muscle. An 11
blade scalpel was used to incise the skin. A 7.0 cannula from Arthrex was
introduced into the glenohumeral joint. The labrum was felt to be
unstable and of poor tissue quality and unrepairable. The superior labrum
was debrided. The biceps tendon had partial tearing along its root. The
biceps tendon was tenotomized. Attention was then turned to the anterior
labrum. The small bony Bankart piece was removed. The anterior neck of
the glenoid was cleared of all soft tissue and decorticated using a 4.0
acromionizer bur. The anterior labrum was mobilized using a periosteal
elevator. Then 4 Griffin anchors were placed on the anterior face of the
glenoid, and these were then passed using a 45 degree suture lasso to the
right. These were tied in a sequential fashion starting from anterior-
inferior to anterior-superior. Once the labral repair was complete,
arthroscopic probe was used to probe the repair and it was felt to be
stable. All the labral repair was complete, all arthroscopic
instrumentation was removed from the shoulder. A 3 cm incision was made
over the anterior lateral aspect of the shoulder. The raphe between the
anterior and medial heads of the deltoid was identified. Blunt dissection
was carried down to identify the intertubercular groove. The sheath
overlying the intertubercular groove was incised with electrocautery.
Biceps tendon was exposed. A single 5.5 Healix anchor was placed in the
intertubercular groove after it was decorticated. The limbs of the 5.5
Healix anchor were threaded in a locking stitch configuration to the
biceps tendon. The biceps tendon was secured within the intertubercular
groove. Copious irrigation was performed. The sheath overlying the
intertubercular groove was closed with 2-0 Vicryl in an interrupted
fashion. Deltoid fascia was closed with 2-0 Vicryl in an interrupted
fashion.
Thank you guys in advance - I don't know what I would do without you!!!
Denise
