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4natlee

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I pretty new to coding and Im coding so op reports for practicode I would appreciate some help

Operative arthroscopy of the left shoulder with arthroscopic assisted excision of the left AC joint.
I have 29805 for the arthroscopy,

I would totaly appreciate some help I am stumped

thank you!!!
 

grm001

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You would need to give a little more detail about the procedure performed in order to get assistance..Sorry
 

4natlee

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DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position and given a left upper extremity interscalene block. She was then given a general anesthesia. The patient was then rolled to right lateral decubitus position on the bean bag with all pressure points well padded and an axillary roll in place. The left arm was placed in longitudinal balance suspension of 15 pounds of dynamic weight with the arm flexed 10 degrees and abducted 20 degrees at the shoulder. We initially started with 12 pounds of dynamic weight, but because of this patient’s arm size, we had to increase our weight, but because of this patient’s arm size, we had to increase our weight for counter balancing. After the left arm and shoulder were prepped with Betadine point solution and draped in the usual orthopedic fashion, we introduced our arthroscopic instruments into the left subacromial space in the usual manner. The posterolateral acromion portal was used for probing, shaving and cutting instruments. The lateral portal was used probing, shaving and cutting instruments. The anterior portal was later made for the excision of the AC joint.

At the onset of the procedure, we could really not see any subacromial structures. The bursa was so thick and so adherent in the soft tissue on the undersurface and the acromion process was too thick, we could not see into the subacromial space. We had to then immediately introduce a 4 mm shaver laterally and used this along with the cautery to do a subacromial bursectomy and debulking the bursa. We also used the shaver and the cautery to remove the soft tissue from the undersurface of the AC joint and also remove it from the undersurface of the acromion process. We then made an anterior portal initially using a spinal needle and isolated our 90 degree position from the long axis of the clavicle for our resection portal. We then introduced a 5 mm egg shaped burr anteriorly and used it for resecting the distal 1 cm of the clavicle and electrocautery was utilized for controlling minimal bleeding. We then measured the width of our resection using 2 full widths of the 5 mm burr. At this time, we then went back in the subacromial space and used the shaver to clean up any debris that was left and then finished doing our subacromial bursectomy. We then inspected the cuff and found no tears and then removed all fluid and instruments from the joint. The wounds were infiltrated with 0.5% Marcaine for postop analgesia. The skin incisions were closed using subcuticular 4-0 Rapide sutures and then we applied Steri-Strips and a sterile compression dressing.




would appreciate any help thanks
 
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