Jennae929
New
I need some help coding for this surgery. I coded 29822,23420,23120 w/ dx 726.10 & 840.4. Is this correct? 
PRE-OP DIAGNOSIS: Right shoulder rotator cuff tear, AC joint arthritis.
POST-OP DIAGNOSIS: Right shoulder rotator cuff tear, AC joint arthritis.
PROCEDURE PERFORMED: Right shoulder arthroscopy with open acromioplasty, distal clavicle excision, rotator cuff repair.
A posterior portal was placed and a camera was inserted. The glenohumeral joint was visualized. Minimal chondral changes were noted on the glenoid and the humerus. The labrum had some slight fraying on the anterior edge of the labrum. The undersurface of the rotator cuff appeared to have some slight fraying. The anterior portal was placed and a shaver was inserted. The anterior labrum was debrided to stable tissue and was noted to be intact. The biceps tendon was brought into the shoulder, was noted to have some erythema, but no tearing or fraying was noted. The undersurface of the rotator cuff was debrided in the area where there was some fraying. The instruments were then removed.
An incision was made on top of the shoulder using Langers lines. Subcutaneous tissue was sharply dissected. Hemostasis was maintained. The subcutaneous tissue was elevated up off of the periosteum. The periosteum was elevated up off of the anterior lateral acromion. An anterior lateral acromioplasty was performed using an oscillating saw. The undersurface of the acromion was rasped to a smooth surface ensuring no remaining spurs were noted. The bursal sac was identified and was removed in its entirety. The supraspinatus tendon was noted to have a full thickness tear which had sort of a U shape to it and was retracted, a very small footprint off of the bone. The bone did have a small bone spur. Using a rongeur the bone spur was removed and the edge of the bone was debrided down to nice cancellous bleeding tissue. Using an Ethibond, the U shaped portion of the tear was brought together and held in place with Ethibond stitches. This was noted to tightly seat the rotator cuff right on the edge of the bone and it was not felt that a suture anchor was warranted. The periosteum was then elevated up off of the distal clavicle. Using an oscillating saw, a 1 cm distal clavicle excision was performed. The wound was copiously irrigated. The periosteum was closed with Ethibond. The subcutaneous tissue was closed with Vicryl. Skin was closed with Prolene. A bulky sterile dressing was applied.
PRE-OP DIAGNOSIS: Right shoulder rotator cuff tear, AC joint arthritis.
POST-OP DIAGNOSIS: Right shoulder rotator cuff tear, AC joint arthritis.
PROCEDURE PERFORMED: Right shoulder arthroscopy with open acromioplasty, distal clavicle excision, rotator cuff repair.
A posterior portal was placed and a camera was inserted. The glenohumeral joint was visualized. Minimal chondral changes were noted on the glenoid and the humerus. The labrum had some slight fraying on the anterior edge of the labrum. The undersurface of the rotator cuff appeared to have some slight fraying. The anterior portal was placed and a shaver was inserted. The anterior labrum was debrided to stable tissue and was noted to be intact. The biceps tendon was brought into the shoulder, was noted to have some erythema, but no tearing or fraying was noted. The undersurface of the rotator cuff was debrided in the area where there was some fraying. The instruments were then removed.
An incision was made on top of the shoulder using Langers lines. Subcutaneous tissue was sharply dissected. Hemostasis was maintained. The subcutaneous tissue was elevated up off of the periosteum. The periosteum was elevated up off of the anterior lateral acromion. An anterior lateral acromioplasty was performed using an oscillating saw. The undersurface of the acromion was rasped to a smooth surface ensuring no remaining spurs were noted. The bursal sac was identified and was removed in its entirety. The supraspinatus tendon was noted to have a full thickness tear which had sort of a U shape to it and was retracted, a very small footprint off of the bone. The bone did have a small bone spur. Using a rongeur the bone spur was removed and the edge of the bone was debrided down to nice cancellous bleeding tissue. Using an Ethibond, the U shaped portion of the tear was brought together and held in place with Ethibond stitches. This was noted to tightly seat the rotator cuff right on the edge of the bone and it was not felt that a suture anchor was warranted. The periosteum was then elevated up off of the distal clavicle. Using an oscillating saw, a 1 cm distal clavicle excision was performed. The wound was copiously irrigated. The periosteum was closed with Ethibond. The subcutaneous tissue was closed with Vicryl. Skin was closed with Prolene. A bulky sterile dressing was applied.