What is the correct way to code the below op report? 29823 or 29822 with 29826? I'm thinking 29823 but am unsure. Thanks in advance!
POSTOPERATIVE DIAGNOSIS: Left shoulder stiffness with partial-thickness tear of the rotator cuff with grade 2 to 3 chondromalacia of the glenoid and a posteroinferior labral tear.
PROCEDURE PERFORMED: Left shoulder arthroscopy with:
1. Lysis of adhesions.
2. Subacromial decompression.
3. Chondroplasty of the glenoid.
4. Debridement of posterior labral tear.
Arthroscopy was begun in the glenohumeral joint. There was some fraying in the rotator interval. However, there was not significant scar tissue noted in the glenohumeral joint. I was able to drive around the joint fairly freely. Looking at the glenoid, there were 2 areas of grade 4 change, centrally very small areas, they are relatively circular and probably about 3 mm in diameter. There was also a tear in the posteroinferior labrum extending into the inferior labrum. At this point, we went ahead and opened the rotator interval and this did seem to open the shoulder a bit, debriding away soft tissue in the interval. The biceps tendon was now palpated and evaluated and retracted into the joint and showed no fraying and no injection and no evidence of SLAP tear. The axillary recess showed normal rotator cuff attachment as did the bare area. There was a small partial undersurface tear at the supraspinatus attachment. This was debrided back to stable tissue. This tear was only 2 to 3 mm, I would estimate. At this point having released the rotator interval, we extended our interval release down the anterior glenoid, staying peripheral to the labrum to around the 7 o'clock position on the glenoid. We then moved to the back of the shoulder and released the posterior capsule just peripheral to the labrum from about 3 o'clock position posteriorly down to about the 6 or 7 o'clock position inferiorly. We went ahead and debrided the labrum, the labral tear in the posteroinferior glenoid back to stable tissue and debrided the inferior labrum back to stable tissue as well. We had previously completed a light chondroplasty of the 2 full-thickness areas in the central glenoid. At this point, the shoulder seemed to be opened fairly nicely and he has had a positive drive-through sign, which suggested a significant release had been performed. At this point, a marker stitch was placed through our partial undersurface tear of the supraspinatus tendon. We then entered the subacromial space and evaluated the area of the marker stitch and the area of the tendon both anterior and posterior to the stitch and medial to lateral and there was no evidence of bursal pathology of the tendon and it was very stable to probing. At this point, attention was turned to the undersurface of the acromion where a partial acromioplasty was performed in cutting block fashion for a moderate anterior spur.
POSTOPERATIVE DIAGNOSIS: Left shoulder stiffness with partial-thickness tear of the rotator cuff with grade 2 to 3 chondromalacia of the glenoid and a posteroinferior labral tear.
PROCEDURE PERFORMED: Left shoulder arthroscopy with:
1. Lysis of adhesions.
2. Subacromial decompression.
3. Chondroplasty of the glenoid.
4. Debridement of posterior labral tear.
Arthroscopy was begun in the glenohumeral joint. There was some fraying in the rotator interval. However, there was not significant scar tissue noted in the glenohumeral joint. I was able to drive around the joint fairly freely. Looking at the glenoid, there were 2 areas of grade 4 change, centrally very small areas, they are relatively circular and probably about 3 mm in diameter. There was also a tear in the posteroinferior labrum extending into the inferior labrum. At this point, we went ahead and opened the rotator interval and this did seem to open the shoulder a bit, debriding away soft tissue in the interval. The biceps tendon was now palpated and evaluated and retracted into the joint and showed no fraying and no injection and no evidence of SLAP tear. The axillary recess showed normal rotator cuff attachment as did the bare area. There was a small partial undersurface tear at the supraspinatus attachment. This was debrided back to stable tissue. This tear was only 2 to 3 mm, I would estimate. At this point having released the rotator interval, we extended our interval release down the anterior glenoid, staying peripheral to the labrum to around the 7 o'clock position on the glenoid. We then moved to the back of the shoulder and released the posterior capsule just peripheral to the labrum from about 3 o'clock position posteriorly down to about the 6 or 7 o'clock position inferiorly. We went ahead and debrided the labrum, the labral tear in the posteroinferior glenoid back to stable tissue and debrided the inferior labrum back to stable tissue as well. We had previously completed a light chondroplasty of the 2 full-thickness areas in the central glenoid. At this point, the shoulder seemed to be opened fairly nicely and he has had a positive drive-through sign, which suggested a significant release had been performed. At this point, a marker stitch was placed through our partial undersurface tear of the supraspinatus tendon. We then entered the subacromial space and evaluated the area of the marker stitch and the area of the tendon both anterior and posterior to the stitch and medial to lateral and there was no evidence of bursal pathology of the tendon and it was very stable to probing. At this point, attention was turned to the undersurface of the acromion where a partial acromioplasty was performed in cutting block fashion for a moderate anterior spur.