Hi list!
I am new to learning ortho and need some help. Would someone please look and please advise?
I have 840.7 for the slap, but what would you code for the posterior labral/bankart tear? 840.8?? or 718.81??
TIA!!!!
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
Type 2 SLAP tear,right
shoulder.
POSTOPERATIVE DIAGNOSES:
Same,plus posterior labral tear
PROCEDURES:
1. Arthroscopic posterior bankart repair ,right shoulder.(29806)
2. Arthroscopic right SLAP repair.(29807)
SURGEON:
ASSISTANT:
xxxx was crucial for the entirety of the procedure.
There was no qualified resident available.
ANESTHESIA:
General with an interscalene block.
ESTIMATED BLOOD LOSS:
50cc
IV FLUIDS:
1500cc
INDICATIONS FOR PROCEDURE:
xxx is a 22 y.o. right hand-dominant male who injured his right shoulder to half months ago playing football. He was throwing and had contact to the shoulder during a throwing motion worse pull backwards and onto the ground. Since then he reported a sharp subacromial and posterior pain. He reports ibuprofen helps a little but he has difficulty with abduction external rotation and overhead motion. He's had no physical therapy injections or surgery.
. He had a physical exam and MRI consistent with a SLAP tear. He was advised of the risks and benefits of operative versus nonoperative treatment. He understood those risks and benefits and agreed to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine on the OR
table, underwent general anesthesia without difficulty. Preop time-out was
done identifyinghisright shoulder as the operative shoulder. He was given preoperative antibiotics and a block in the holding area. He was placed into beach chair position with all bony prominences padded, prepped and draped in sterile fashion using ChloraPrep. The limb was elevated and the examination under anesthesia revealed a full range of motion in abduction of his
right shoulder and normal stability. He was prepped and draped in sterile fashion using ChloraPrep. The arthroscopy was begun using a posterior
portal. We immediately proceeded to the rotator cuff interval, made our
outside-in portal, began the diagnostic arthroscopy with the following
findings. The patient had an intact biceps tendon. However, with abduction and
external rotation of the shoulder, there was a positive peel-back sign
and bare superior glenoid consistent with type 2 SLAP tear.
The anterior, inferior labrum were otherwise intact. However there was also a posterior bankart tear that extended down to the 7 oclock region.The
subscapularis had some fraying, but it was also attached well to the
lesser tuberosity. Examination of the supraspinatus revealed no tear.
We then made an anterior postal to help pass the sutures for our SLAP repair. We prepared the glenoid with a rasp and shaver and then placed 3 push lock anchors with meniscal cinch stitches at 10:30 and 11:30 and a mattress stitch at the biceps anchor and SGHL anteriorly. This gave us good coaptaion and reduction of our SLAP tear and was stable to probing. We then switched our camera to the anterior portal and made a 7 oclock portal to help with the posterior bankart repair. We placed 2 anchors, one at 7:30 and one at 8:30. The 7:30 anchor was a suture tac and we passed 2 simple stiches and tied knots. The 8:30 anchor was a push lock with a meniscal cinch. This gave us good coaptation and reduction of the posterior tear. We probed both the SLAP and Bankart repairs and they were stable.
Once this was accomplished, we removed the arthroscopic tools from the joint, closed the portals using interrupted 3.0 nylon stitches in
A matress fashion.We put Xeroform over the portals and
Steri-Strips over the axillary incision. Dressing, sponges, ABD, foam tape
and an Sling were applied. The patient tolerated the procedure well
and was transferred to the recovery room in stable condition.
Postoperatively, He will be in an Sling for approximately 2 weeks. We
will see the patient back in the clinic in 10-14 days for repeat evaluation and
suture removal. We will start physical therapy on my SLAP repair protocol 2 weeks postoperatively.
I am new to learning ortho and need some help. Would someone please look and please advise?
I have 840.7 for the slap, but what would you code for the posterior labral/bankart tear? 840.8?? or 718.81??
TIA!!!!
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
Type 2 SLAP tear,right
shoulder.
POSTOPERATIVE DIAGNOSES:
Same,plus posterior labral tear
PROCEDURES:
1. Arthroscopic posterior bankart repair ,right shoulder.(29806)
2. Arthroscopic right SLAP repair.(29807)
SURGEON:
ASSISTANT:
xxxx was crucial for the entirety of the procedure.
There was no qualified resident available.
ANESTHESIA:
General with an interscalene block.
ESTIMATED BLOOD LOSS:
50cc
IV FLUIDS:
1500cc
INDICATIONS FOR PROCEDURE:
xxx is a 22 y.o. right hand-dominant male who injured his right shoulder to half months ago playing football. He was throwing and had contact to the shoulder during a throwing motion worse pull backwards and onto the ground. Since then he reported a sharp subacromial and posterior pain. He reports ibuprofen helps a little but he has difficulty with abduction external rotation and overhead motion. He's had no physical therapy injections or surgery.
. He had a physical exam and MRI consistent with a SLAP tear. He was advised of the risks and benefits of operative versus nonoperative treatment. He understood those risks and benefits and agreed to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine on the OR
table, underwent general anesthesia without difficulty. Preop time-out was
done identifyinghisright shoulder as the operative shoulder. He was given preoperative antibiotics and a block in the holding area. He was placed into beach chair position with all bony prominences padded, prepped and draped in sterile fashion using ChloraPrep. The limb was elevated and the examination under anesthesia revealed a full range of motion in abduction of his
right shoulder and normal stability. He was prepped and draped in sterile fashion using ChloraPrep. The arthroscopy was begun using a posterior
portal. We immediately proceeded to the rotator cuff interval, made our
outside-in portal, began the diagnostic arthroscopy with the following
findings. The patient had an intact biceps tendon. However, with abduction and
external rotation of the shoulder, there was a positive peel-back sign
and bare superior glenoid consistent with type 2 SLAP tear.
The anterior, inferior labrum were otherwise intact. However there was also a posterior bankart tear that extended down to the 7 oclock region.The
subscapularis had some fraying, but it was also attached well to the
lesser tuberosity. Examination of the supraspinatus revealed no tear.
We then made an anterior postal to help pass the sutures for our SLAP repair. We prepared the glenoid with a rasp and shaver and then placed 3 push lock anchors with meniscal cinch stitches at 10:30 and 11:30 and a mattress stitch at the biceps anchor and SGHL anteriorly. This gave us good coaptaion and reduction of our SLAP tear and was stable to probing. We then switched our camera to the anterior portal and made a 7 oclock portal to help with the posterior bankart repair. We placed 2 anchors, one at 7:30 and one at 8:30. The 7:30 anchor was a suture tac and we passed 2 simple stiches and tied knots. The 8:30 anchor was a push lock with a meniscal cinch. This gave us good coaptation and reduction of the posterior tear. We probed both the SLAP and Bankart repairs and they were stable.
Once this was accomplished, we removed the arthroscopic tools from the joint, closed the portals using interrupted 3.0 nylon stitches in
A matress fashion.We put Xeroform over the portals and
Steri-Strips over the axillary incision. Dressing, sponges, ABD, foam tape
and an Sling were applied. The patient tolerated the procedure well
and was transferred to the recovery room in stable condition.
Postoperatively, He will be in an Sling for approximately 2 weeks. We
will see the patient back in the clinic in 10-14 days for repeat evaluation and
suture removal. We will start physical therapy on my SLAP repair protocol 2 weeks postoperatively.