Can someone help me with this? Not sure where to go with the CPT. The dx was subscapularis sprain/strain - 840.5. Thanks!
...longitudinal incision was made along the anterior part of his shoulder, incorporating the prior scar, and deepened through the subcutaneous tissue. The deltoid and pectoralis fascia tissue was identified. Flaps were created. The deltopectoral interval was identified. The cephalic vein was identified and retracted laterally. The coracoid tendon was then identified. The conjoined tendon was then noted. The clavipectoral fascia was then divided in line with its fibers. Deep retractors were positioned. Great care was taken to protect the axillary musculocutaneous nerves, which were protected throughout all segments of the procedure using the retractors and sponges. Next, scar tissue was debrided. The subscapularis tendon was identified by putting that structure into stretch. There was a tear measured as previously described. The most superior aspect of the tendon was avulsed off of the lesser tuberosity, but there was a stout segment of remaining tendon on the lesser tuberosity. Therefore, with the arm at approximately 10 degrees of external rotation, the interstitial tearing of the subscapularis tendon was repaired with interrupted #1 Vicryl sutures in a mattress configuration. Once that was performed, the body and distal aspect of the subscapularis was mobilized, and a repair was then performed using interrupted #1 Vicryl sutures to the cuff of tissue that was remaining on the lesser tuberosity. A stout repair was able to be achieved. Upon completion of the repair, the elbow was placed against the patient's side, and the patient could easily achieve 45 degrees of external rotation with no undue tension. Of note, the rotator interval was assessed and noted to be intact. There was no tearing of the capsule. The wound was then copiously irrigated with normal saline solution. The deltopectoral interval was closed with interrupted 2-0 Vicryl sutures. The subcutaneous tissue was closed with 3-0 Vicryl suture, and the skin was closed with staples. The wound was thoroughly cleaned. A sterile dressing was applied consisting of antibiotic ointment, Adaptic, 4 x 4, an ABD, and a sling. He tolerated the procedure well with brisk refill in his digits upon completion of the procedure.
...longitudinal incision was made along the anterior part of his shoulder, incorporating the prior scar, and deepened through the subcutaneous tissue. The deltoid and pectoralis fascia tissue was identified. Flaps were created. The deltopectoral interval was identified. The cephalic vein was identified and retracted laterally. The coracoid tendon was then identified. The conjoined tendon was then noted. The clavipectoral fascia was then divided in line with its fibers. Deep retractors were positioned. Great care was taken to protect the axillary musculocutaneous nerves, which were protected throughout all segments of the procedure using the retractors and sponges. Next, scar tissue was debrided. The subscapularis tendon was identified by putting that structure into stretch. There was a tear measured as previously described. The most superior aspect of the tendon was avulsed off of the lesser tuberosity, but there was a stout segment of remaining tendon on the lesser tuberosity. Therefore, with the arm at approximately 10 degrees of external rotation, the interstitial tearing of the subscapularis tendon was repaired with interrupted #1 Vicryl sutures in a mattress configuration. Once that was performed, the body and distal aspect of the subscapularis was mobilized, and a repair was then performed using interrupted #1 Vicryl sutures to the cuff of tissue that was remaining on the lesser tuberosity. A stout repair was able to be achieved. Upon completion of the repair, the elbow was placed against the patient's side, and the patient could easily achieve 45 degrees of external rotation with no undue tension. Of note, the rotator interval was assessed and noted to be intact. There was no tearing of the capsule. The wound was then copiously irrigated with normal saline solution. The deltopectoral interval was closed with interrupted 2-0 Vicryl sutures. The subcutaneous tissue was closed with 3-0 Vicryl suture, and the skin was closed with staples. The wound was thoroughly cleaned. A sterile dressing was applied consisting of antibiotic ointment, Adaptic, 4 x 4, an ABD, and a sling. He tolerated the procedure well with brisk refill in his digits upon completion of the procedure.