Can someone please help? I am trying to code this op note below... I get code 23550 but the physician says that he also did 23446 but I don't see it. Can someone please take a look at this and see if I am missing the Capsulorrhaphy somewhere? Thanks in advance for any help you can provide!
DESCRIPTION OF PROCEDURE: The patient was seen and evaluated in the preoperative suite.
Correct site was identified and marked. Preoperative antibiotics were given within one hour of surgical
incision. Interscalene block was provided by the anesthesiologist in the preoperative area for pain control.
She was then to the operative suite and placed in the supine position. General anesthesia was induced.
She was then placed in the beachchair position. All bony prominences were carefully padded. Her head
was placed in the well padded head holder and legs were well padded. Torso was flexed at 60 degrees.
All bony prominences were carefully padded. The area was then prepped and draped in standard usual
sterile fashion. Prior to starting the case, a correct site and time-out were again performed.
We then examined the right shoulder under anesthesia. Her AC joint on her right side, we could translate
it anteriorly almost a 100% and reduced it in its neutral position. No posterior instability. No
superoinferior instability. No generalized shoulder instability as well. Once this was done, we marked our
bony landmarks, made a transverse incision based over AC joint, cauterizing all superficial bleeders. We
dissected her skin on both sides and incised periosteum over her AC joint to carefully protect this for
closure later. We then identified her AC joint, cleared off her acromion as well as her AC joint about 1.5
cm on either side of this. We then drilled the hole, tapped the hole for anchor in the acromion protecting
its undersurface and filling the undersurface to make sure we did not feel any protrusion of the anchor.
There was bone on all sides of our guidepin. We tapped the anchor, placed our Arthrex FiberTape loaded
3.5 mm PEEK SwiveLock anchor, tested, it was nice and stable. We then placed the guidepin 1.5 cm
medial on the clavicle, used our drill, tapped, placed another 3.5 mm PEEK SwiveLock anchor. We then
estimated the tension of this, marked this on the FiberTape. We then reduced the clavicle and then
reduced the anchor on the clavicle with appropriate tension. We tied the anchor down. We removed our
instrumentation, checked our stability, it was nice and stable, cut our FiberTape. We then repaired the
periosteal capsule layer over the AC joint. Once this was done, this was done with the #2 FiberWire that
was preloaded on the anchor. We then closed the subcutaneous with 2-0 Monocryl and skin with running
3-0 subcuticular Monocryl. We then test this for stability, it was nice and stable, could not translate or
dislocate it anteriorly. Steri-Strips and a sterile dressing was applied. The patient was awoken, placed in a
sling, awoken and transferred to the PACU in stable satisfactory condition.
DESCRIPTION OF PROCEDURE: The patient was seen and evaluated in the preoperative suite.
Correct site was identified and marked. Preoperative antibiotics were given within one hour of surgical
incision. Interscalene block was provided by the anesthesiologist in the preoperative area for pain control.
She was then to the operative suite and placed in the supine position. General anesthesia was induced.
She was then placed in the beachchair position. All bony prominences were carefully padded. Her head
was placed in the well padded head holder and legs were well padded. Torso was flexed at 60 degrees.
All bony prominences were carefully padded. The area was then prepped and draped in standard usual
sterile fashion. Prior to starting the case, a correct site and time-out were again performed.
We then examined the right shoulder under anesthesia. Her AC joint on her right side, we could translate
it anteriorly almost a 100% and reduced it in its neutral position. No posterior instability. No
superoinferior instability. No generalized shoulder instability as well. Once this was done, we marked our
bony landmarks, made a transverse incision based over AC joint, cauterizing all superficial bleeders. We
dissected her skin on both sides and incised periosteum over her AC joint to carefully protect this for
closure later. We then identified her AC joint, cleared off her acromion as well as her AC joint about 1.5
cm on either side of this. We then drilled the hole, tapped the hole for anchor in the acromion protecting
its undersurface and filling the undersurface to make sure we did not feel any protrusion of the anchor.
There was bone on all sides of our guidepin. We tapped the anchor, placed our Arthrex FiberTape loaded
3.5 mm PEEK SwiveLock anchor, tested, it was nice and stable. We then placed the guidepin 1.5 cm
medial on the clavicle, used our drill, tapped, placed another 3.5 mm PEEK SwiveLock anchor. We then
estimated the tension of this, marked this on the FiberTape. We then reduced the clavicle and then
reduced the anchor on the clavicle with appropriate tension. We tied the anchor down. We removed our
instrumentation, checked our stability, it was nice and stable, cut our FiberTape. We then repaired the
periosteal capsule layer over the AC joint. Once this was done, this was done with the #2 FiberWire that
was preloaded on the anchor. We then closed the subcutaneous with 2-0 Monocryl and skin with running
3-0 subcuticular Monocryl. We then test this for stability, it was nice and stable, could not translate or
dislocate it anteriorly. Steri-Strips and a sterile dressing was applied. The patient was awoken, placed in a
sling, awoken and transferred to the PACU in stable satisfactory condition.