dsibley67
Networker
Good morning, fellow coders! Need a second opinion, please. I don't see the extensive debridement, but I am hoping that maybe someone else will be able to help me identify the extensive debridment. I have 23430 for the open procedure. Would I be able to bill both codes. There is no NCCI edits that I see. Op note:
The upper border of the subscapularis was intact. The patient had
bicipital erythema throughout. The patient had articular sided rotator cuff tearing. There was no loose bodies in the axillary recess. The patient had a very diminutive posterior labrum, she had injection and
erythema throughout the shoulder, soft tissues with synovitis. The patient did not have any glenohumeral
osteoarthritis. The patient had Buford complex anteriorly with very diminutive/no anterior labrum.
Following the diagnostic arthroscopy, I elected to proceed with subpectoral biceps tenodesis, given
erythema and SLAP tearing present. The scissors was placed in the anterior portal and cut at the base
stump. I debrided some of the synovitis anteriorly and used electrocautery to tighten up the patulous labral
tissue as well as obtained hemostasis. I then inserted a shaver and debrided the articular side of the
posterior rotator cuff and also there was some patulous tissue posteriorly that I debrided away with the
shaver. We obtained hemostasis with electrocautery. I then went up into the subacromial space. The
patient had a large amount of bursal inflammation. I made a lateral portal under direct visualization with a
spinal needle. I inserted a shaver. I debrided the bursal tissue. I then obtained hemostasis with
electrocautery as well as peeled off the inferior border of the periosteum and acromion and used a shaver
to remove periosteum as well. The subdeltoid and subacromial bursitis was removed. I then went in the
lateral portal, placed switching stick in the lateral portal and visualized and removed more inflammatory
tissue and then inserted anteriorly and debrided some of the anterior bursal tissue. Following this,
hemostasis was obtained. There was no full-thickness rotator cuff tears. I then proceeded with open
portion of the case, where I made a 4 cm incision in one of the axillary folds and went through skin and
subcutaneous tissue, palpated the inferior border of the pectoralis. I then digitally probed. I then freed up
space onto the humerus and made sure I was directly on the humerus. I placed a Hohmann retractor
there and then a self-retaining retractor for the soft tissue superficially. I cleared off the synovitis. I
palpated the biceps tendon and identified it. I removed the biceps stump from the wound and I removed
the synovitis off of the biceps tendon down to the near the musculotendinous junction. I then did a
FiberLoop stitch and five passes at the fit being a locking stitch. I then cut the remainder of the stump and
then I palpated the proximal portion of the bicipital groove. There was still large amount of synovitis which
I removed with a Bovie. I was down on the humeral surface. I then used a key elevator and then used to
enter the FiberTak stitch suture anchor. This was done under power, I malleted it in. I set the anchor and
then I took the FiberWire. I shuttled through the anchor and tightened it down onto bone and then tied it.
I then used a free needle and stitched each limb back through the biceps tendon and then tied down.
Everything was snug and moving as a unit. I irrigated with copious amounts of saline and then did a
layered closure with 3-0 Monocryl followed by running 3-0 Monocryl and then Dermabond, Steri-Strips,
4x4, Tegaderm were placed in the axillary wound and then three portal incisions were closed with 3-0
nylon, Xeroform, 4x4, ABD, Medipore tape. The patient will be remained in the sling. The patient was
successfully woken from anesthesia and taken to PACU in stable condition.
The upper border of the subscapularis was intact. The patient had
bicipital erythema throughout. The patient had articular sided rotator cuff tearing. There was no loose bodies in the axillary recess. The patient had a very diminutive posterior labrum, she had injection and
erythema throughout the shoulder, soft tissues with synovitis. The patient did not have any glenohumeral
osteoarthritis. The patient had Buford complex anteriorly with very diminutive/no anterior labrum.
Following the diagnostic arthroscopy, I elected to proceed with subpectoral biceps tenodesis, given
erythema and SLAP tearing present. The scissors was placed in the anterior portal and cut at the base
stump. I debrided some of the synovitis anteriorly and used electrocautery to tighten up the patulous labral
tissue as well as obtained hemostasis. I then inserted a shaver and debrided the articular side of the
posterior rotator cuff and also there was some patulous tissue posteriorly that I debrided away with the
shaver. We obtained hemostasis with electrocautery. I then went up into the subacromial space. The
patient had a large amount of bursal inflammation. I made a lateral portal under direct visualization with a
spinal needle. I inserted a shaver. I debrided the bursal tissue. I then obtained hemostasis with
electrocautery as well as peeled off the inferior border of the periosteum and acromion and used a shaver
to remove periosteum as well. The subdeltoid and subacromial bursitis was removed. I then went in the
lateral portal, placed switching stick in the lateral portal and visualized and removed more inflammatory
tissue and then inserted anteriorly and debrided some of the anterior bursal tissue. Following this,
hemostasis was obtained. There was no full-thickness rotator cuff tears. I then proceeded with open
portion of the case, where I made a 4 cm incision in one of the axillary folds and went through skin and
subcutaneous tissue, palpated the inferior border of the pectoralis. I then digitally probed. I then freed up
space onto the humerus and made sure I was directly on the humerus. I placed a Hohmann retractor
there and then a self-retaining retractor for the soft tissue superficially. I cleared off the synovitis. I
palpated the biceps tendon and identified it. I removed the biceps stump from the wound and I removed
the synovitis off of the biceps tendon down to the near the musculotendinous junction. I then did a
FiberLoop stitch and five passes at the fit being a locking stitch. I then cut the remainder of the stump and
then I palpated the proximal portion of the bicipital groove. There was still large amount of synovitis which
I removed with a Bovie. I was down on the humeral surface. I then used a key elevator and then used to
enter the FiberTak stitch suture anchor. This was done under power, I malleted it in. I set the anchor and
then I took the FiberWire. I shuttled through the anchor and tightened it down onto bone and then tied it.
I then used a free needle and stitched each limb back through the biceps tendon and then tied down.
Everything was snug and moving as a unit. I irrigated with copious amounts of saline and then did a
layered closure with 3-0 Monocryl followed by running 3-0 Monocryl and then Dermabond, Steri-Strips,
4x4, Tegaderm were placed in the axillary wound and then three portal incisions were closed with 3-0
nylon, Xeroform, 4x4, ABD, Medipore tape. The patient will be remained in the sling. The patient was
successfully woken from anesthesia and taken to PACU in stable condition.