Provider wants to bill for CPT CODES 23412, 29825 AND 29822, I only see 23412 Any help would be appreciated
PROCEDURE NOTE
Preprocedure diagnosis: left rotator cuff tear
Left rotator cuff tendonitis tendiopathy
Left capsular scarring
Post-Procedure Diagnosis: left supraspinatus tear
Left rotator cuff tendonitis tendinopathy
Left Capsular scarring
Procedure(s) (Description):
Left Mini Open Supraspinatus Rotator Cuff Repair
Left acromioplasty debridement
Left capsular release manipulation under anesthesia
Anesthesia: Regional and General
Disposition: Stable to Recovery Room
Indication:
A 57-year-old female with ongoing left shoulder pain and dysfunction not
responding to conservative measures to her satisfaction. Imaging and
exam were consistent with rotator cuff tearing, rotator cuff
tendinopathy, and diminished range of motion. As such, felt she would
be best served with arthroscopy to deal with shoulder more definitively.
Risks and benefits were explained preoperatively. The patient gave
informed consent.
Findings:
SEE ABOVE
Left shoulder diagnostic arthroscopy revealed normal attachment for
infraspinatus, teres minor and subscapularis. Tearing in the
supraspinatus was identified. Significant intraarticular inflammation
was noted with biceps normally attached, but no significant inflammation
of the biceps. Glenoid and humeral head chondral surfaces showed no
significant chondromalacia changes. Her labrum was otherwise normally
attached. Thickened capsule with the inflammatory changes prompted
interval debridement for release of the rotator interval.
Subacromially, extensive subacromial and subdeltoid bursal thickening
and scarring were identified and debrided with shaver to reconstitute
the spaces. Acromioplasty debridement for the tight subacromial space,
cuff tearing and tendinopathy was carried out with standard technique.
The tear was repaired with 2 medial and 2 lateral anchors with
SpeedBridge technique with incorporation of biologic reduction implant.
Good stable rotator cuff repair was noted at the end of this.
Manipulation under anesthesia yielded 180 of forward flexion, 90 of
external rotation and abduction, 50 of internal rotation and abduction
with notable release of the capsular manipulation. Inspection of the
cuff repair with biologic reduction implant showed it to be stable,
unchanged after manipulation.
Procedure:
The patient was identified in the preop surgical area. Operative upper extremity was marked with the surgeon's initials. The patient was brought into the operative suite and placed in the supine position. Anesthesia was obtained per standard technique. Subsequently, the patient was placed into the lateral decubitus position with the nonoperative shoulder down. Care was taken to make sure that the axillary roll was well placed in the axilla to protect the neurovascular structures. Care was taken also to well pad the Peroneal Nerve on the lower leg as well as place a pillow between the knees with the knees flexed to avoid any excessive pressure on the neurovascular structures. The patient was secured in the lateral decubitus position using a beanbag and pads as required. Prepping and draping was then carried out on the operative shoulder per the standard technique.
Subsequently, a sterile traction device was secured to the operative arm and the arm placed in standard traction for a lateral decubitus arthroscopy with approximately 10 pounds of traction. Lidocaine with epinephrine was infiltrated into the proposed arthroscopy portal sites. An 11-blade was used to incise the skin in the standard posterior shoulder portal site location. A cannula with a blunt trocar was introduced through the posterior incision into the joint without difficulty taking care to avoid any injury to the humeral or glenoid chondral surfaces. The scope was introduced. Under direct visualization, needle localization was used to obtain the anterior portal location lateral to the Coracoid. The spinal needle was removed and an 11-blade used to incise just the skin. A blunt trocar was used to introduce the cannula into the shoulder anteriorly between the Biceps and the Subscapularis tendons. Care was taken to make sure that this portal was lateral to the Coracoid to avoid injury to the neurovascular structures anteriorly. Subsequently, a standard diagnostic inspection of the joint was carried out without difficulty. The diagnostic arthroscopy was carried out alternating between the anterior and posterior portals. Finds are as indicated in the `Operative Findings' section. Interval debridement release was carried out arthroscopically
Attention was turned to the Subacromial Space. Using a posterolateral acromial incision, a posterolateral portal to the Subacromial Space was obtained. An 11-blade was used to only incise the skin. A blunt trocar was used to introduce the cannula in the Subacromial Space. Subsequently, the scope was introduced. At this time, a lateral acromial portal was identified under needle localization. An 11-blade was used to incise the skin; after which, the shaver was introduced into this lateral acromial portal. A bursectomy and debridement of the scarred and inflamed bursae was carried out to allow adequate visualization subacromially.
With this complete, visualization and inspection determined that the Subacromial Decompression was appropriate. Attention was turned to debriding the undersurface of the acromion itself. A Bovie/ablator device and shaver were used to accomplish this. The anterior as well as anterolateral aspect of the acromion was then identified. The acromion was burred back to the level of the clavicle anteriorly using a barrel burr through the lateral portal. Care was taken at this point to coagulate the bleeder of the Thoracoacromial Arch. Subsequently, the scope was placed in the lateral acromial portal and the acromionizer burr brought in through the posterior portal. Using the posterior acromion as a template, the down slope of the anterior acromion was removed turning the acromion into a Type I acromion. Care was taken to avoid thinning the acromion excessively. With this complete, the scope was again placed in the posterolateral acromial portal. The burr was brought in through the lateral acromial portal. Holding the shaver perpendicular to the floor to serve as a guide, the lateral slope of the acromion was removed smoothing out and flattening the acromial lateral aspect. Once this was complete, good decompression of the Subacromial Space was noted and there was good clearance for the rotator cuff.
Attention was turned to the rotator cuff tear. The scope was removed and excess fluid drained from the shoulder. The lateral acromial portal was extended longitudinally approximately 5 cm. Blunt dissection was carried down to the deltoid itself. The deltoid was split in line with its fibers at most carrying this split 5 cm from the acromion itself. Once the Subacromial Space was entered, a retaining stitch at the apex of the deltoid split was placed to avoid any injury to the Axillary Nerve. The tear was visualized in its entire extent. Initiation of the repair was carried out at this point as indicated in the `Operative Findings'. Subsequently, the tuberosity itself was prepared through the lateral portal lightly debriding the cortical bone so as not to expose excess subcortical bone. Preparation was carried to the articular margin at this time. Pacement of medial anchors was carried out. The fiber tape suture from each anchor was placed through the cuff using fiberloop. Once all tapes and sutures were placed, the cuff was repaired back to bone using standard speedbridge technique. The tapes and sutures were sequentially threaded through lateral repair anchors prior to placement of the anchors into the lateral tuberosity using standard technique. As each anchor was placed, the sutures were tensioned prior to tightening the screw. The tapes and sutures were cut at the appropriate length. Incorporation of a biologic induction implant was done per standard technique. Good stable rotator cuff repair and implant was noted at this time as well as rotation of the shoulder and a good broad cuff footprint reestablished. Subsequently, copious irrigation was carried out in the Subacromial Space to remove any cancellous bony fragments. The self-retaining retractor was removed; after which, palpation of the Acromion was done to insure appropriate bony resection.
Manipulation under anesthesia was done yielding 180 forward flexion, 90 external rotation in abduction and 50 internal rotation under anesthesia.
The deltoid split was repaired taking care to secure the deltoid fascia using 0 Vicryl to reapproximate the deltoid. The subcutaneous tissues were subsequently closed with interrupted 2-0 Vicryl followed by a running 3-0 Monocryl subcuticular stitch. Benzoin followed by Steri-Strips was placed over the lateral acromial mini rotator cuff repair incision. The remaining incisions were closed with an interrupted nylon stitch at the portals. The incisions were injected at this time. All incisions were dressed sterilely with Adaptic followed by 4x4s and sterile ABD. The dressings were held in place while the operative field was taken down and the arm was taken out of the traction-holding device. The dressings were taped in place. The arm was placed into a sling with pillow prior to turning the patient supine. The patient's general anesthesia was reversed. The patient was taken to the Recovery Room in stable condition. Block was obtained per Anesthesia.
PROCEDURE NOTE
Preprocedure diagnosis: left rotator cuff tear
Left rotator cuff tendonitis tendiopathy
Left capsular scarring
Post-Procedure Diagnosis: left supraspinatus tear
Left rotator cuff tendonitis tendinopathy
Left Capsular scarring
Procedure(s) (Description):
Left Mini Open Supraspinatus Rotator Cuff Repair
Left acromioplasty debridement
Left capsular release manipulation under anesthesia
Anesthesia: Regional and General
Disposition: Stable to Recovery Room
Indication:
A 57-year-old female with ongoing left shoulder pain and dysfunction not
responding to conservative measures to her satisfaction. Imaging and
exam were consistent with rotator cuff tearing, rotator cuff
tendinopathy, and diminished range of motion. As such, felt she would
be best served with arthroscopy to deal with shoulder more definitively.
Risks and benefits were explained preoperatively. The patient gave
informed consent.
Findings:
SEE ABOVE
Left shoulder diagnostic arthroscopy revealed normal attachment for
infraspinatus, teres minor and subscapularis. Tearing in the
supraspinatus was identified. Significant intraarticular inflammation
was noted with biceps normally attached, but no significant inflammation
of the biceps. Glenoid and humeral head chondral surfaces showed no
significant chondromalacia changes. Her labrum was otherwise normally
attached. Thickened capsule with the inflammatory changes prompted
interval debridement for release of the rotator interval.
Subacromially, extensive subacromial and subdeltoid bursal thickening
and scarring were identified and debrided with shaver to reconstitute
the spaces. Acromioplasty debridement for the tight subacromial space,
cuff tearing and tendinopathy was carried out with standard technique.
The tear was repaired with 2 medial and 2 lateral anchors with
SpeedBridge technique with incorporation of biologic reduction implant.
Good stable rotator cuff repair was noted at the end of this.
Manipulation under anesthesia yielded 180 of forward flexion, 90 of
external rotation and abduction, 50 of internal rotation and abduction
with notable release of the capsular manipulation. Inspection of the
cuff repair with biologic reduction implant showed it to be stable,
unchanged after manipulation.
Procedure:
The patient was identified in the preop surgical area. Operative upper extremity was marked with the surgeon's initials. The patient was brought into the operative suite and placed in the supine position. Anesthesia was obtained per standard technique. Subsequently, the patient was placed into the lateral decubitus position with the nonoperative shoulder down. Care was taken to make sure that the axillary roll was well placed in the axilla to protect the neurovascular structures. Care was taken also to well pad the Peroneal Nerve on the lower leg as well as place a pillow between the knees with the knees flexed to avoid any excessive pressure on the neurovascular structures. The patient was secured in the lateral decubitus position using a beanbag and pads as required. Prepping and draping was then carried out on the operative shoulder per the standard technique.
Subsequently, a sterile traction device was secured to the operative arm and the arm placed in standard traction for a lateral decubitus arthroscopy with approximately 10 pounds of traction. Lidocaine with epinephrine was infiltrated into the proposed arthroscopy portal sites. An 11-blade was used to incise the skin in the standard posterior shoulder portal site location. A cannula with a blunt trocar was introduced through the posterior incision into the joint without difficulty taking care to avoid any injury to the humeral or glenoid chondral surfaces. The scope was introduced. Under direct visualization, needle localization was used to obtain the anterior portal location lateral to the Coracoid. The spinal needle was removed and an 11-blade used to incise just the skin. A blunt trocar was used to introduce the cannula into the shoulder anteriorly between the Biceps and the Subscapularis tendons. Care was taken to make sure that this portal was lateral to the Coracoid to avoid injury to the neurovascular structures anteriorly. Subsequently, a standard diagnostic inspection of the joint was carried out without difficulty. The diagnostic arthroscopy was carried out alternating between the anterior and posterior portals. Finds are as indicated in the `Operative Findings' section. Interval debridement release was carried out arthroscopically
Attention was turned to the Subacromial Space. Using a posterolateral acromial incision, a posterolateral portal to the Subacromial Space was obtained. An 11-blade was used to only incise the skin. A blunt trocar was used to introduce the cannula in the Subacromial Space. Subsequently, the scope was introduced. At this time, a lateral acromial portal was identified under needle localization. An 11-blade was used to incise the skin; after which, the shaver was introduced into this lateral acromial portal. A bursectomy and debridement of the scarred and inflamed bursae was carried out to allow adequate visualization subacromially.
With this complete, visualization and inspection determined that the Subacromial Decompression was appropriate. Attention was turned to debriding the undersurface of the acromion itself. A Bovie/ablator device and shaver were used to accomplish this. The anterior as well as anterolateral aspect of the acromion was then identified. The acromion was burred back to the level of the clavicle anteriorly using a barrel burr through the lateral portal. Care was taken at this point to coagulate the bleeder of the Thoracoacromial Arch. Subsequently, the scope was placed in the lateral acromial portal and the acromionizer burr brought in through the posterior portal. Using the posterior acromion as a template, the down slope of the anterior acromion was removed turning the acromion into a Type I acromion. Care was taken to avoid thinning the acromion excessively. With this complete, the scope was again placed in the posterolateral acromial portal. The burr was brought in through the lateral acromial portal. Holding the shaver perpendicular to the floor to serve as a guide, the lateral slope of the acromion was removed smoothing out and flattening the acromial lateral aspect. Once this was complete, good decompression of the Subacromial Space was noted and there was good clearance for the rotator cuff.
Attention was turned to the rotator cuff tear. The scope was removed and excess fluid drained from the shoulder. The lateral acromial portal was extended longitudinally approximately 5 cm. Blunt dissection was carried down to the deltoid itself. The deltoid was split in line with its fibers at most carrying this split 5 cm from the acromion itself. Once the Subacromial Space was entered, a retaining stitch at the apex of the deltoid split was placed to avoid any injury to the Axillary Nerve. The tear was visualized in its entire extent. Initiation of the repair was carried out at this point as indicated in the `Operative Findings'. Subsequently, the tuberosity itself was prepared through the lateral portal lightly debriding the cortical bone so as not to expose excess subcortical bone. Preparation was carried to the articular margin at this time. Pacement of medial anchors was carried out. The fiber tape suture from each anchor was placed through the cuff using fiberloop. Once all tapes and sutures were placed, the cuff was repaired back to bone using standard speedbridge technique. The tapes and sutures were sequentially threaded through lateral repair anchors prior to placement of the anchors into the lateral tuberosity using standard technique. As each anchor was placed, the sutures were tensioned prior to tightening the screw. The tapes and sutures were cut at the appropriate length. Incorporation of a biologic induction implant was done per standard technique. Good stable rotator cuff repair and implant was noted at this time as well as rotation of the shoulder and a good broad cuff footprint reestablished. Subsequently, copious irrigation was carried out in the Subacromial Space to remove any cancellous bony fragments. The self-retaining retractor was removed; after which, palpation of the Acromion was done to insure appropriate bony resection.
Manipulation under anesthesia was done yielding 180 forward flexion, 90 external rotation in abduction and 50 internal rotation under anesthesia.
The deltoid split was repaired taking care to secure the deltoid fascia using 0 Vicryl to reapproximate the deltoid. The subcutaneous tissues were subsequently closed with interrupted 2-0 Vicryl followed by a running 3-0 Monocryl subcuticular stitch. Benzoin followed by Steri-Strips was placed over the lateral acromial mini rotator cuff repair incision. The remaining incisions were closed with an interrupted nylon stitch at the portals. The incisions were injected at this time. All incisions were dressed sterilely with Adaptic followed by 4x4s and sterile ABD. The dressings were held in place while the operative field was taken down and the arm was taken out of the traction-holding device. The dressings were taped in place. The arm was placed into a sling with pillow prior to turning the patient supine. The patient's general anesthesia was reversed. The patient was taken to the Recovery Room in stable condition. Block was obtained per Anesthesia.