Can some help with the CPT codes for this? Provider is looking at 23440 and 29826. Help us....
POSTOPERATIVE DIAGNOSIS:
1. Left type 2 superior labrum anterior to posterior lesion. 2. Shoulder tendinitis.
OPERATIVE PROCEDURE:
1. Open subpectoral biceps tenodesis.
2. Arthroscopic decompression.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
After adequate preoperative evaluation, the patient was placed in the supine position on the operating room table. After adequate general endotracheal anesthesia was obtained, the patient was placed in right lateral position. The patient's right upper extremity and lower extremities were well padded on egg crate and pillows. With the cervical spine in neutral position, the knees were slightly flexed. The arm suspended in 40 degrees abduction and 20 degrees of forward flexion, 10 pounds of traction.
The scope was placed posteriorly [/COLOR]and the working portal anteriorly. Evaluation of the glenohumeral joint showed a type 2 SLAP lesion with fraying of the biceps tendon. Through the anterior portal the biceps tendon was released and the superior labrum was debrided back to stable surface. The glenohumeral head was pristine as was the rotator cuff was pristine.
Next, the shoulder was taken out of traction. Arm was reprepped with Betadine. A 5 cm skin incision was made centered at the inferior edge of the pectoralis major insertion onto the humerus. Blunt dissection was carried down to the fascia and opened in line with the incision and dissection carried subpectoral which was done with the Hohmann to expose the biceps tendon. The guide pin was placed and was drilled with a 7.5 mm drill. All bone debris was copiously irrigated with GU solution. With the elbow in full extension the biceps tendon was sized to the level of the drill hole and cut. A stitch of #2 FiberWire was placed, modified Krakow stitch, was then loaded into a 7 mm Arthrex Bio-Tenodesis screw which screwed into the humerus tenodesing the biceps tendon to the proximal humerus.
All wounds were copiously irrigated with GU solution. The shoulder placed back in 40 degrees of abduction and 20 degrees of forward flexion . The scope was placed up the subacromial space. Working portal lateral, inflow anteriorly. The coracoacromial was released. The scope was transferred laterally, notchplasty blade posteriorly, type 2 acromion was converted straight with acromioplasty. The acromion was straight as viewed laterally. Close inspection of the rotator cuff showed no full-
thickness tear. The scope was taken back posteriorly. The acromion was perfectly straight as viewed posteriorly and therefore straight in both planes.
The patient tolerated the procedure well with no complications. Soft dressing applied, placed in an arm sling and transported to the recovery room without incident.
The skin incision had been closed with 4-0 nylon.
POSTOPERATIVE DIAGNOSIS:
1. Left type 2 superior labrum anterior to posterior lesion. 2. Shoulder tendinitis.
OPERATIVE PROCEDURE:
1. Open subpectoral biceps tenodesis.
2. Arthroscopic decompression.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
After adequate preoperative evaluation, the patient was placed in the supine position on the operating room table. After adequate general endotracheal anesthesia was obtained, the patient was placed in right lateral position. The patient's right upper extremity and lower extremities were well padded on egg crate and pillows. With the cervical spine in neutral position, the knees were slightly flexed. The arm suspended in 40 degrees abduction and 20 degrees of forward flexion, 10 pounds of traction.
The scope was placed posteriorly [/COLOR]and the working portal anteriorly. Evaluation of the glenohumeral joint showed a type 2 SLAP lesion with fraying of the biceps tendon. Through the anterior portal the biceps tendon was released and the superior labrum was debrided back to stable surface. The glenohumeral head was pristine as was the rotator cuff was pristine.
Next, the shoulder was taken out of traction. Arm was reprepped with Betadine. A 5 cm skin incision was made centered at the inferior edge of the pectoralis major insertion onto the humerus. Blunt dissection was carried down to the fascia and opened in line with the incision and dissection carried subpectoral which was done with the Hohmann to expose the biceps tendon. The guide pin was placed and was drilled with a 7.5 mm drill. All bone debris was copiously irrigated with GU solution. With the elbow in full extension the biceps tendon was sized to the level of the drill hole and cut. A stitch of #2 FiberWire was placed, modified Krakow stitch, was then loaded into a 7 mm Arthrex Bio-Tenodesis screw which screwed into the humerus tenodesing the biceps tendon to the proximal humerus.
All wounds were copiously irrigated with GU solution. The shoulder placed back in 40 degrees of abduction and 20 degrees of forward flexion . The scope was placed up the subacromial space. Working portal lateral, inflow anteriorly. The coracoacromial was released. The scope was transferred laterally, notchplasty blade posteriorly, type 2 acromion was converted straight with acromioplasty. The acromion was straight as viewed laterally. Close inspection of the rotator cuff showed no full-
thickness tear. The scope was taken back posteriorly. The acromion was perfectly straight as viewed posteriorly and therefore straight in both planes.
The patient tolerated the procedure well with no complications. Soft dressing applied, placed in an arm sling and transported to the recovery room without incident.
The skin incision had been closed with 4-0 nylon.