Wiki 29826 & 29825-operative diagnosis


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Good afternoon, can you please take a look at this op-note & confirm my code selection: 29826 & 29825. Thanks in advance!

PRE/POST-OPERATIVE DIAGNOSIS: Right shoulder impingement w/secondary frozen shoulder.


FINDINGS: At the time of surgery revealed audible lysis of adhesions with manipulation under anesthesia and inflamed synovitic capsule consistent with frozen shoulder and a narrowed subacromial space consistent with impingement for which manipulation, decompression, and capsular release were performed.

PROCEDURE: Regional and LMA were induced. Manipulation under anesthesia was then performed with gentle flexion and traction. Audible lysis of adhesions was noted from 150 to 180. Similar adhesions were lysed with external rotation with the arm at the side holding in the supracondylar area so as to avoid injury to the elbow ligaments. Internal and external rotation was performed at 90 degrees of abduction also with adduction. The patient was then placed in a beachchair position and the left arm was draped and prepped in the usual sterile manner. IV antibiotics were administered and a standard posterior portal was used and the blunt trocar into the joint. An organized inspection of the joint revealed severely synovitic and inflamed synovial capsule and narrowed joint space consistent with frozen shoulder. An anterior portal was placed. Through this portal, a thermal electro wand was used to perform a capsular release. We released the rotator interval. The coracohumeral ligament and superior glenohumeral ligament were then extended inferiorly and anteriorly, the anterior and anteroinferior middle glenohumeral ligaments until we had circumferentially released the capsule. All hemostasis was obtained. There was inspection of the rotator cuff, found it to be intact, as well as the biceps tendon and articular surfaces. We brought the arthroscope up into the subacromial space. We identified a very inflamed narrowed space consistent with impingement. A third portal was placed anterolaterally. Through this portal, we performed a bursectomy and released the soft tissue from the undersurface of the acromion, and released the coracoacromial ligament. A 5.5 acromionizer was then used from medial to lateral and anterior to posterior to lift the anterior and inferior surface decompressing the rotator cuff and transforming this into a flat type 1 acromion without further impingement on the rotator cuff beneath it. Once this was done, we then brought the arthroscope into the anterolateral portal and confirmed that this was indeed a flat acromion with no further impingement on the cuff and inspected the rotator cuff and found it to be completely intact. Further suctioning was performed and a lateral gutter was shaved in order to remove the bursa in this area. We obtained hemostasis, removed the instrumentation, and closed the portals with 3-0 nylon sutures.