Hi, the surgeon wants me to code this surgery with 29806 and I don't think the documentation justifies that. Help!
Description of Procedure(s):
Patient was taken the operating the supine position after excellent general anesthetic patient was placed in semisitting position right upper extremity clearly shoulder was prepped and draped in usual sterile fashion. Shoulder was placed through passive full range of motion there is no instability. Right shoulder was arthroscoped with a 25 degree 5 mm arthroscope this introduced a posterior portal. Glenohumeral joint was free of arthritic changes bicep tendon was intact mid third glenohumeral ligament is intact. There is a massive rotator cuff tear retracted nearly to the glenoid labrum involving the supraspinatus and infraspinatus and anterior portion of the subscapularis. There is no significant arthritic changes the arthroscope was withdrawn an anterolateral bike incision was made of the tip the acromion carried down through subcutaneous tissue subcutaneous flaps were developed. The deltoid was split vertically direction was fibers and teed off the anterolateral tip of the acromion subacromial space was entered hypertrophic bursa was excised. Acromioplasty was carried out with a power and hand instruments in standard fashion relieving all impingement. The rotator cuff was grasped and 3 released of adhesions with elevators. The greater tuberosity had a large hypertrophic osteophyte which was debrided. After performing the acromioplasty with a power and hand instruments this relieved impingement. Next 2 anchors were placed in the medial row 4.75 x 19.1 mm these were Arthrex anchors and bioabsorbable in nature. These were passed through the anterior and posterior borders of the rotator cuff. A second row in a crisscross fashion of anchors 4.75 x 19.1 mm was used 1 anteriorly and 1 posteriorly in a crisscross fashion. This produced good integrity to the repair. Some of the subscapularis and infraspinatus was repaired also in a side-to-side fashion with interrupted #2 Ethibond sutures. There is good integrity to the repair no impingement and full range of motion. Wound was irrigated check for hemostasis the deltoid was reattached through drill holes to the anterolateral tip of the acromion with an operative #2 Ethibond sutures deltoid fascia was oversewn with 0 Vicryl sutures sub-tissues closed with 2-0 Vicryl suture skin was closed with 3-0 Monocryl sutures and Steri-Strips. Sterile dressings were applied.
Finding(s): Massive right rotator cuff tear with impingement
Description of Procedure(s):
Patient was taken the operating the supine position after excellent general anesthetic patient was placed in semisitting position right upper extremity clearly shoulder was prepped and draped in usual sterile fashion. Shoulder was placed through passive full range of motion there is no instability. Right shoulder was arthroscoped with a 25 degree 5 mm arthroscope this introduced a posterior portal. Glenohumeral joint was free of arthritic changes bicep tendon was intact mid third glenohumeral ligament is intact. There is a massive rotator cuff tear retracted nearly to the glenoid labrum involving the supraspinatus and infraspinatus and anterior portion of the subscapularis. There is no significant arthritic changes the arthroscope was withdrawn an anterolateral bike incision was made of the tip the acromion carried down through subcutaneous tissue subcutaneous flaps were developed. The deltoid was split vertically direction was fibers and teed off the anterolateral tip of the acromion subacromial space was entered hypertrophic bursa was excised. Acromioplasty was carried out with a power and hand instruments in standard fashion relieving all impingement. The rotator cuff was grasped and 3 released of adhesions with elevators. The greater tuberosity had a large hypertrophic osteophyte which was debrided. After performing the acromioplasty with a power and hand instruments this relieved impingement. Next 2 anchors were placed in the medial row 4.75 x 19.1 mm these were Arthrex anchors and bioabsorbable in nature. These were passed through the anterior and posterior borders of the rotator cuff. A second row in a crisscross fashion of anchors 4.75 x 19.1 mm was used 1 anteriorly and 1 posteriorly in a crisscross fashion. This produced good integrity to the repair. Some of the subscapularis and infraspinatus was repaired also in a side-to-side fashion with interrupted #2 Ethibond sutures. There is good integrity to the repair no impingement and full range of motion. Wound was irrigated check for hemostasis the deltoid was reattached through drill holes to the anterolateral tip of the acromion with an operative #2 Ethibond sutures deltoid fascia was oversewn with 0 Vicryl sutures sub-tissues closed with 2-0 Vicryl suture skin was closed with 3-0 Monocryl sutures and Steri-Strips. Sterile dressings were applied.
Finding(s): Massive right rotator cuff tear with impingement