dsibley67
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- Southaven, MS
Very conflicted on how to code this operative note. Not sure if I should code 29806 & 29827 or 29806, 29807-59, 29999. Per research I have read that you should not code 29827 for the Remplissage d/t the 29827 is included. I know with the second set of CPT code that normally you wouldn't bill 29806 & 29807 together but both procedures were done. I am just really unsure of how t code this appropriately. Any help would be greatly appreciated. Below is the operative note.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder Bankart lesion with anterior shoulder instability
.2. Right shoulder Hill-Sachs deformity.3. Partial-thickness right infraspinatus tear.
PROCEDURES PERFORMED:1. Right shoulder arthroscopy with labral repair and capsulorrhaphy.
2. Right shoulder arthroscopy remplissage via infraspinatus tenodesis.
3. Infraspinatus rotator cuff repair.
INDICATIONS FOR PROCEDURE: The patient is a pleasant 16-year-old male who presented to my office after referral from one of my partners for recurrent shoulder instability to the right shoulder. Hehad trialed a course of nonoperative treatment, activity modifications, and therapy without significant relief.He had continued instability episodes with athletic participation. Given this and in correlation with his advanced imaging that demonstrated a Hill-Sachs deformity with some partial-thickness infraspinatustearing and anterior labral Bankart, I discussed with him operative intervention to the right shoulder toinclude right shoulder arthroscopy with capsulorrhaphy, SLAP repair, and remplissage with possible rotatorcuff repair with the infraspinatus via tenodesis into the Hill-Sachs deformity. I discussed risks, benefitsand alternatives of surgery. Specific risks discussed included, but not limited to infection, blood loss,damage to surrounding neurovascular structures, DVT, PE, the need for further surgery, recurrentinstability, postoperative stiffness, inability to return to athletic participation, and the general risk ofanesthesia. After weighing his options, he expressed understanding and elected to proceed with surgery.
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area, prior toinitiation of any medication and the operative extremity was marked with indelible pen. The appropriatelaterality was confirmed verbally with the patient and any remaining questions were answered in theirentirety to the patient's satisfaction. The patient then was taken to the operative suite where generalanesthesia with LMA was administered by the Anesthesia team. The patient had obvious anteriorinstability and was placed into lateral decubitus position with the affected extremity placing the ceiling. Anaxillary roll was used. All downed extremities were well-padded. The right upper extremity was preppedand draped in usual sterile fashion. A formal time-out to include the administration of antibiotics, theappropriate laterality, the availability of all necessary implants and any questions or concerns by surgicalteam were addressed and confirmed.I then marked out the bony landmarks on lateral portion of the shoulder to include the lateral acromion,scapular spine, AC joint, and Neviaser portal as well as the coracoid. I used an 11 blade to make astandard posterior portal on the shoulder. A blunt scope trocar was used to enter the posterior portion ofglenohumeral joint. The arthroscope was introduced. Diagnostic arthroscopy was completed. He hadtearing and blunting of the anterior labrum down to the anteroinferior articular surface. He had laxity ofthe posteroinferior glenohumeral ligament. Cartilage surfaces were intact. He had a type I SLAP tear.He had high-grade partial-thickness undersurface tearing of the infraspinatus with underlying Hill-Sachsdeformity. The supraspinatus undersurface was intact. The biceps was normally maintained in the slingwithout tearing.I turned my attention creating working portals. I made a high anterosuperior lateral portal and introduced8.25 cannula. I then made anterior glenoid portal under direct visualization just superior to the subscap,also placed an 8.25 mm cannula. Once the portals were created, I used an arthroscopic liberator to definethe anterior labral tear. I also freed up the tear along the posteroinferior labrum near the PIGHL. Iintroduced a cannula posteriorly. I placed all-suture 1.8 Arthrex knotless anchor at the 7 o'clock position.I used a 90-degree lasso to then pass a suture through the posteroinferior glenohumeral ligament. This hadexcellent reduction of posteroinferior glenohumeral ligament to improve stability. While in that position, Iwas able to view the Hill-Sachs deformity. I debrided the Hill-Sachs deformity with a curved curette anda shaver. I then backed the cannula outside of the infraspinatus tendon, percutaneously placed two 1.8FiberTak anchors for the infraspinatus tenodesis. I had debrided the undersurface tearing of theinfraspinatus. This would allow for repair of the infraspinatus tendon with partial-thickness tearing back to the appropriate footprint. After it says this completed the anterior capsulorrhaphy and labral repair, Iwould say I then made a port of Wilmington at the myotendinous junction of the supraspinatus. I placed a1.5 FiberTak anchor at the posterior attachment of the biceps labral complex. I then passed the lasso andrepair stitch sequentially. This was tightened but not over-constrained to repair the type I SLAP tear.This completed the SLAP repair.I placed the inferior anchor first and then the superior anchor appeared provisionally past the knotlessmechanism without completely tightening it to not decrease visualization. I then removed the cannula withthe switching stick reestablishing the posterior portal. I then moved back to the posterior portal, beganworking on the anterior portion of labrum. I again used a liberator to completely free up the anterior andanteroinferior labrum in order to expose the subscapularis muscle belly. Once I had excellent mobility ofthe labrum, I then passed a SutureTape in a horizontal mattress configuration at the anteroinferiorglenohumeral ligament entering the labrum. I then drilled and placed a FiberTak anchor in approximatelythe 5:30 position. This had excellent reduction and tightening of the anteroinferior glenohumeral ligamentand the labrum. I then subsequently placed two 1.8 mm FiberTak anchors along the anterior portion of theglenoid below the sublabral foramen. This again had excellent reduction of the labral tissue with goodtightening of the anterior capsule to complete the capsulorrhaphy. Viewing from the anterosuperior portalhad excellent centering of the humeral head at that time. This completed the anterior capsulorrhaphy andlabral repair.While viewing from the anterosuperior portal, I then sequentially tightened the remplissage anchors. Thishad good reduction of the infraspinatus tearing back down to the infraspinatus footprint. This also hadexcellent fill of the Hill-Sachs deformity. This completed the remplissage and rotator cuff repair viainfraspinatus tenodesis.I then used a bird-beak with 0 PDS through the posterior portal to close the posterior portal to preventpropagation. All permanent arthroscopic images were saved. Again, there was great restoration of thecapsular bumper at the posteroinferior, anteroinferior and anterior portions of the glenoid. Good centeringof the humeral head. No obvious translation. All instruments were removed. Surgical counts werecorrect. I drained the excess fluid. The portals were closed with 3-0 nylon sutures in portal fashion.Sterile dressing was applied. The patient was placed in abduction sling. The patient was awakened fromanesthesia and transferred to PACU in stable condition.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder Bankart lesion with anterior shoulder instability
.2. Right shoulder Hill-Sachs deformity.3. Partial-thickness right infraspinatus tear.
PROCEDURES PERFORMED:1. Right shoulder arthroscopy with labral repair and capsulorrhaphy.
2. Right shoulder arthroscopy remplissage via infraspinatus tenodesis.
3. Infraspinatus rotator cuff repair.
INDICATIONS FOR PROCEDURE: The patient is a pleasant 16-year-old male who presented to my office after referral from one of my partners for recurrent shoulder instability to the right shoulder. Hehad trialed a course of nonoperative treatment, activity modifications, and therapy without significant relief.He had continued instability episodes with athletic participation. Given this and in correlation with his advanced imaging that demonstrated a Hill-Sachs deformity with some partial-thickness infraspinatustearing and anterior labral Bankart, I discussed with him operative intervention to the right shoulder toinclude right shoulder arthroscopy with capsulorrhaphy, SLAP repair, and remplissage with possible rotatorcuff repair with the infraspinatus via tenodesis into the Hill-Sachs deformity. I discussed risks, benefitsand alternatives of surgery. Specific risks discussed included, but not limited to infection, blood loss,damage to surrounding neurovascular structures, DVT, PE, the need for further surgery, recurrentinstability, postoperative stiffness, inability to return to athletic participation, and the general risk ofanesthesia. After weighing his options, he expressed understanding and elected to proceed with surgery.
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area, prior toinitiation of any medication and the operative extremity was marked with indelible pen. The appropriatelaterality was confirmed verbally with the patient and any remaining questions were answered in theirentirety to the patient's satisfaction. The patient then was taken to the operative suite where generalanesthesia with LMA was administered by the Anesthesia team. The patient had obvious anteriorinstability and was placed into lateral decubitus position with the affected extremity placing the ceiling. Anaxillary roll was used. All downed extremities were well-padded. The right upper extremity was preppedand draped in usual sterile fashion. A formal time-out to include the administration of antibiotics, theappropriate laterality, the availability of all necessary implants and any questions or concerns by surgicalteam were addressed and confirmed.I then marked out the bony landmarks on lateral portion of the shoulder to include the lateral acromion,scapular spine, AC joint, and Neviaser portal as well as the coracoid. I used an 11 blade to make astandard posterior portal on the shoulder. A blunt scope trocar was used to enter the posterior portion ofglenohumeral joint. The arthroscope was introduced. Diagnostic arthroscopy was completed. He hadtearing and blunting of the anterior labrum down to the anteroinferior articular surface. He had laxity ofthe posteroinferior glenohumeral ligament. Cartilage surfaces were intact. He had a type I SLAP tear.He had high-grade partial-thickness undersurface tearing of the infraspinatus with underlying Hill-Sachsdeformity. The supraspinatus undersurface was intact. The biceps was normally maintained in the slingwithout tearing.I turned my attention creating working portals. I made a high anterosuperior lateral portal and introduced8.25 cannula. I then made anterior glenoid portal under direct visualization just superior to the subscap,also placed an 8.25 mm cannula. Once the portals were created, I used an arthroscopic liberator to definethe anterior labral tear. I also freed up the tear along the posteroinferior labrum near the PIGHL. Iintroduced a cannula posteriorly. I placed all-suture 1.8 Arthrex knotless anchor at the 7 o'clock position.I used a 90-degree lasso to then pass a suture through the posteroinferior glenohumeral ligament. This hadexcellent reduction of posteroinferior glenohumeral ligament to improve stability. While in that position, Iwas able to view the Hill-Sachs deformity. I debrided the Hill-Sachs deformity with a curved curette anda shaver. I then backed the cannula outside of the infraspinatus tendon, percutaneously placed two 1.8FiberTak anchors for the infraspinatus tenodesis. I had debrided the undersurface tearing of theinfraspinatus. This would allow for repair of the infraspinatus tendon with partial-thickness tearing back to the appropriate footprint. After it says this completed the anterior capsulorrhaphy and labral repair, Iwould say I then made a port of Wilmington at the myotendinous junction of the supraspinatus. I placed a1.5 FiberTak anchor at the posterior attachment of the biceps labral complex. I then passed the lasso andrepair stitch sequentially. This was tightened but not over-constrained to repair the type I SLAP tear.This completed the SLAP repair.I placed the inferior anchor first and then the superior anchor appeared provisionally past the knotlessmechanism without completely tightening it to not decrease visualization. I then removed the cannula withthe switching stick reestablishing the posterior portal. I then moved back to the posterior portal, beganworking on the anterior portion of labrum. I again used a liberator to completely free up the anterior andanteroinferior labrum in order to expose the subscapularis muscle belly. Once I had excellent mobility ofthe labrum, I then passed a SutureTape in a horizontal mattress configuration at the anteroinferiorglenohumeral ligament entering the labrum. I then drilled and placed a FiberTak anchor in approximatelythe 5:30 position. This had excellent reduction and tightening of the anteroinferior glenohumeral ligamentand the labrum. I then subsequently placed two 1.8 mm FiberTak anchors along the anterior portion of theglenoid below the sublabral foramen. This again had excellent reduction of the labral tissue with goodtightening of the anterior capsule to complete the capsulorrhaphy. Viewing from the anterosuperior portalhad excellent centering of the humeral head at that time. This completed the anterior capsulorrhaphy andlabral repair.While viewing from the anterosuperior portal, I then sequentially tightened the remplissage anchors. Thishad good reduction of the infraspinatus tearing back down to the infraspinatus footprint. This also hadexcellent fill of the Hill-Sachs deformity. This completed the remplissage and rotator cuff repair viainfraspinatus tenodesis.I then used a bird-beak with 0 PDS through the posterior portal to close the posterior portal to preventpropagation. All permanent arthroscopic images were saved. Again, there was great restoration of thecapsular bumper at the posteroinferior, anteroinferior and anterior portions of the glenoid. Good centeringof the humeral head. No obvious translation. All instruments were removed. Surgical counts werecorrect. I drained the excess fluid. The portals were closed with 3-0 nylon sutures in portal fashion.Sterile dressing was applied. The patient was placed in abduction sling. The patient was awakened fromanesthesia and transferred to PACU in stable condition.