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Orthopedic Coding Alert

READER QUESTIONS:

Ante Up Your Ortho Diagnosis Possibilities

Published on Mon Oct 04, 2010

Question: Our surgeon submitted the following operative note, but we can't determine which ICD-9 code applies. Should we report all of them or just one? "A frayed and detached superior anterior labrum with detachment of the junction of the anterior superior and anterior portion of the labrum and about 90 percent detachment of the anterior aspect of the labrum right at the biceps tendon anchor. Some fraying of the  posterior superior labrum but no detachment, and no detachment of the biceps tendon anchor itself. Some synovitis especially anteriorly and superiorly. "No evidence of any rotator cuff tear. The middle glenohumeral ligament was somewhat frayed, and the patient did appear to have some subtle laxity anteriorly, increased from the opposite side both on exam under anesthesia and when viewing through the arthroscope. The remainder of the patient's labrum appeared normal. The subacromial space appeared without any significant synovitis, and the rotator [...]
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