cclarson
Guru
Hello Everyone, I'm trying to decipher this dictation and figure out if this warrants both 29806 and 29807, or just 29807. I think that it would be only 29807 w/ 29822-59 based on the documentation. Thoughts?
POSTOPERATIVE DIAGNOSES:
1. Right shoulder posterior labral tear.
2. Right shoulder superior labrum anterior and posterior tear.
3. Right shoulder partial-thickness rotator cuff tear.
PROCEDURES PERFORMED:
1. Right shoulder arthroscopic posterior labral repair, CPT code 29806.
2. Right shoulder arthroscopic superior labrum anterior and posterior repair, CPT code 29807.
3. Right shoulder arthroscopic rotator cuff debridement.
INDICATIONS FOR SURGERY: The patient is a 34-year-old male who sustained an injury at work when it was stuck in as he was attempting to dislodge and he felt pain in his shoulder. He had undergone conservative treatment of this including anti-inflammatories, modification of activities, but continued to have significant pain and dysfunction. He was sent to me for evaluation and treatment. I was concerned about the possibility of a posterior labral tear. An MRI was obtained, which confirmed a large posterior labral tear, and he also appeared to have a SLAP type of tear and some fraying of the underside of his supraspinatus and infraspinatus insertion. Given his failure of conservative treatment and the large size of his tear, I recommended surgical intervention. I recommended arthroscopic repair of his posterior labral tear with likely repair of his superior labral tear component. I discussed debridement versus repair of his rotator cuff tear as well. The risks, benefits, and alternatives were discussed including the risk of bleeding, infection, failure of any repair, continued shoulder pain and dysfunction, and possible need for more surgery. The patient understood these risks and agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. His H&P and consent form were signed and updated. He was taken to the operating room. After, a regional block was placed. He was intubated and sedated. He was placed in the lateral position with his right side up. His right upper extremity was prepped and draped in a normal sterile fashion. Preoperative antibiotics were given.
After a surgical time-out was performed, we started with the posterior portal. I made this just off the posterolateral corner of the acromion and entered the glenohumeral space and then made our anterior portal under direct visualization. I made the first one little bit more medially, so we could put a large cannula in here to serve as a working cannula. I then made a second portal site more superior and laterally up towards the insertion of the subscapularis. I decided first to work anteriorly while viewing from the posterior portal. We used the probe to examine the joint first and defined our pathology. He did not have any significant degenerative changes in the glenohumeral joint. His biceps tendon was intact. His subscapularis was intact with just a little bit of fraying around the superior edge. We debrided this back with a shaver to a stable edge. The rotator cuff insertion of the supraspinatus and infraspinatus also had some undersurface tearing out at the footprint. I debrided this with a shaver as well back to a stable base. I did not think that it involved more than 10-15% of the rotator cuff footprint, so I did not need any sort of repair. Finally, we looked at our pathology of labrum. He had a very large labral tear. This extended from about 7 o'clock posterior position all the way up to the entirety of the posterior labrum, the entirety of the superior labrum, and then going into about the 2 o'clock position or so in the anterior labrum. The anteroinferior portion of the labrum was intact.
As mentioned, I decided to work on the anterior portion first. I used a shaver to debride this anterior labrum. I elected to place an anchor up at about the 1 o'clock position or so. I thought that this would both stabilize the extension of the tear into the anterior labrum and then also stabilize our biceps insertion. We used an Arthrex PushLock anchor repair. I used a SutureLasso and grabbed underneath the entirety of the labrum. We grabbed the lasso from our accessory portal and passed the suture through this lasso and then pulled the suture passer back through the labrum. We then grabbed the other end of the LabralTape, and this allowed us to circumferential suture around the labrum. We then drilled for and placed our PushLock anchor at about the 1 o'clock position. This provided a nice repair of our anterior and superior labrum. It seemed to be very stable after this repair.
At this point, we switched and started viewing from the anterior accessory portal and then working through our posterior portal. We enlarged this to place a larger cannula back here. I actually thought we had good position with our initial portal placement and did not need any accessory portals. We repeated the same process using the PushLock anchor from Arthrex and using the SutureLasso to pass through the labrum first and then placed our anchor. We ended up placing 3 posterior labral anchors, 1 down about the 8 o'clock position, 1 at about the 9:30 position, and then 1 up close to 11 o'clock position. These provided excellent stability of the posterior labrum. I also thawed our superior labral insertion. Now with the biceps tendon was intact and did not need any further repairs. Final arthroscopic images were obtained to confirm our repair and stability of the labrum.
At this point, we removed our arthroscopic instruments. We closed the portal sites with nylon sutures. Sterile dressings were applied. The patient's arm was placed in a sling. He was awakened from anesthesia and taken to the recovery area in stable condition.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder posterior labral tear.
2. Right shoulder superior labrum anterior and posterior tear.
3. Right shoulder partial-thickness rotator cuff tear.
PROCEDURES PERFORMED:
1. Right shoulder arthroscopic posterior labral repair, CPT code 29806.
2. Right shoulder arthroscopic superior labrum anterior and posterior repair, CPT code 29807.
3. Right shoulder arthroscopic rotator cuff debridement.
INDICATIONS FOR SURGERY: The patient is a 34-year-old male who sustained an injury at work when it was stuck in as he was attempting to dislodge and he felt pain in his shoulder. He had undergone conservative treatment of this including anti-inflammatories, modification of activities, but continued to have significant pain and dysfunction. He was sent to me for evaluation and treatment. I was concerned about the possibility of a posterior labral tear. An MRI was obtained, which confirmed a large posterior labral tear, and he also appeared to have a SLAP type of tear and some fraying of the underside of his supraspinatus and infraspinatus insertion. Given his failure of conservative treatment and the large size of his tear, I recommended surgical intervention. I recommended arthroscopic repair of his posterior labral tear with likely repair of his superior labral tear component. I discussed debridement versus repair of his rotator cuff tear as well. The risks, benefits, and alternatives were discussed including the risk of bleeding, infection, failure of any repair, continued shoulder pain and dysfunction, and possible need for more surgery. The patient understood these risks and agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. His H&P and consent form were signed and updated. He was taken to the operating room. After, a regional block was placed. He was intubated and sedated. He was placed in the lateral position with his right side up. His right upper extremity was prepped and draped in a normal sterile fashion. Preoperative antibiotics were given.
After a surgical time-out was performed, we started with the posterior portal. I made this just off the posterolateral corner of the acromion and entered the glenohumeral space and then made our anterior portal under direct visualization. I made the first one little bit more medially, so we could put a large cannula in here to serve as a working cannula. I then made a second portal site more superior and laterally up towards the insertion of the subscapularis. I decided first to work anteriorly while viewing from the posterior portal. We used the probe to examine the joint first and defined our pathology. He did not have any significant degenerative changes in the glenohumeral joint. His biceps tendon was intact. His subscapularis was intact with just a little bit of fraying around the superior edge. We debrided this back with a shaver to a stable edge. The rotator cuff insertion of the supraspinatus and infraspinatus also had some undersurface tearing out at the footprint. I debrided this with a shaver as well back to a stable base. I did not think that it involved more than 10-15% of the rotator cuff footprint, so I did not need any sort of repair. Finally, we looked at our pathology of labrum. He had a very large labral tear. This extended from about 7 o'clock posterior position all the way up to the entirety of the posterior labrum, the entirety of the superior labrum, and then going into about the 2 o'clock position or so in the anterior labrum. The anteroinferior portion of the labrum was intact.
As mentioned, I decided to work on the anterior portion first. I used a shaver to debride this anterior labrum. I elected to place an anchor up at about the 1 o'clock position or so. I thought that this would both stabilize the extension of the tear into the anterior labrum and then also stabilize our biceps insertion. We used an Arthrex PushLock anchor repair. I used a SutureLasso and grabbed underneath the entirety of the labrum. We grabbed the lasso from our accessory portal and passed the suture through this lasso and then pulled the suture passer back through the labrum. We then grabbed the other end of the LabralTape, and this allowed us to circumferential suture around the labrum. We then drilled for and placed our PushLock anchor at about the 1 o'clock position. This provided a nice repair of our anterior and superior labrum. It seemed to be very stable after this repair.
At this point, we switched and started viewing from the anterior accessory portal and then working through our posterior portal. We enlarged this to place a larger cannula back here. I actually thought we had good position with our initial portal placement and did not need any accessory portals. We repeated the same process using the PushLock anchor from Arthrex and using the SutureLasso to pass through the labrum first and then placed our anchor. We ended up placing 3 posterior labral anchors, 1 down about the 8 o'clock position, 1 at about the 9:30 position, and then 1 up close to 11 o'clock position. These provided excellent stability of the posterior labrum. I also thawed our superior labral insertion. Now with the biceps tendon was intact and did not need any further repairs. Final arthroscopic images were obtained to confirm our repair and stability of the labrum.
At this point, we removed our arthroscopic instruments. We closed the portal sites with nylon sutures. Sterile dressings were applied. The patient's arm was placed in a sling. He was awakened from anesthesia and taken to the recovery area in stable condition.