dyoungberg
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Our doctor performed a diagnostic shoulder arthroscopy, subacromial decompression and limited debridement of bursal side rotator cuff. Since 29826 is now an add on code and can't be billed separately, I am struggling with how to correctly code the procedure. Does anyone have an idea of how I might code this procedure?
PREOP DIAGNOSIS: ROTATOR CUFF TEAR LEFT SHOULDER
POSTOP DIAGNOSIS:
1. IMPINGEMENT LEFT SHOULDER
2. PARTIAL THICKNESS BURSAL SURFACE ARTICULAR TEAR ROTATOR CUFF LEFT SHOULDER
PROCEDURE:
1. DIAGNOSTIC ARTHROSCOPY LEFT SHOULDER
2. ARTHROSCOPIC SUBACROMIAL DECOMPRESSION LEFT SHOULDER
3. LIMITED DEBRIDEMENT OF BURSAL SURFACE ROTATOR CUFF TEAR LEFT SHOULDER
ANESTHESIA: GENERAL
CLINICAL FINDINGS: The biceps labral complex was intact. The articular surfaces were intact. There was a full ROM. There was a type III acromion. There was perhaps a 10% thickness bursal surface tear as noted above.
PROCEDURE: The patient was brought to the OR where general anesthesia was induced without incident. The patient was intubated without complication. He was placed in the beach chair position and bony prominences were well padded. EUA demonstrated a normal ROM of the shoulder. The lateral aspect of the shoulder was prepared with Betadine. The shoulder was insufflated with Lidocaine w/epi 1:100,000 and normal saline. The left shoulder and arm were prepped and draped free in the usual sterile manner.
A standard diagnostic arthroscopy was performed introducing the scope into the posterior soft spot and advancing into the safe triangle. Wissinger rod technique was used to create an anterior portal and all intraarticular structures were evaluated and palpated.
A suspicious area was marked with a suture.
Instruments were redirected into the subdeltoid space where a decompression was performed in the manner described by Caspari, levering the bur off the undersurface of the scapular spine thus performing a partial anterolateral acromionectomy. The CA ligament was released with the tissue ablator.
A careful debridement of the bursal surface tear was done and it was not substantial enough to repair. The shoulder was copiously irrigated and sucked dry. Arthroscopic instrumentation was removed. The wounds were closed with staples. The shoulder was insufflated with a mixture of Ropivacaine and MS. A sterile dressing was applied.
The patient was extubated, transferred to the recovery room stretcher, and taken to recovery without incident.
Thanks!
PREOP DIAGNOSIS: ROTATOR CUFF TEAR LEFT SHOULDER
POSTOP DIAGNOSIS:
1. IMPINGEMENT LEFT SHOULDER
2. PARTIAL THICKNESS BURSAL SURFACE ARTICULAR TEAR ROTATOR CUFF LEFT SHOULDER
PROCEDURE:
1. DIAGNOSTIC ARTHROSCOPY LEFT SHOULDER
2. ARTHROSCOPIC SUBACROMIAL DECOMPRESSION LEFT SHOULDER
3. LIMITED DEBRIDEMENT OF BURSAL SURFACE ROTATOR CUFF TEAR LEFT SHOULDER
ANESTHESIA: GENERAL
CLINICAL FINDINGS: The biceps labral complex was intact. The articular surfaces were intact. There was a full ROM. There was a type III acromion. There was perhaps a 10% thickness bursal surface tear as noted above.
PROCEDURE: The patient was brought to the OR where general anesthesia was induced without incident. The patient was intubated without complication. He was placed in the beach chair position and bony prominences were well padded. EUA demonstrated a normal ROM of the shoulder. The lateral aspect of the shoulder was prepared with Betadine. The shoulder was insufflated with Lidocaine w/epi 1:100,000 and normal saline. The left shoulder and arm were prepped and draped free in the usual sterile manner.
A standard diagnostic arthroscopy was performed introducing the scope into the posterior soft spot and advancing into the safe triangle. Wissinger rod technique was used to create an anterior portal and all intraarticular structures were evaluated and palpated.
A suspicious area was marked with a suture.
Instruments were redirected into the subdeltoid space where a decompression was performed in the manner described by Caspari, levering the bur off the undersurface of the scapular spine thus performing a partial anterolateral acromionectomy. The CA ligament was released with the tissue ablator.
A careful debridement of the bursal surface tear was done and it was not substantial enough to repair. The shoulder was copiously irrigated and sucked dry. Arthroscopic instrumentation was removed. The wounds were closed with staples. The shoulder was insufflated with a mixture of Ropivacaine and MS. A sterile dressing was applied.
The patient was extubated, transferred to the recovery room stretcher, and taken to recovery without incident.
Thanks!