karismithx
Contributor
I have a doctor who'll dictate "rotator cuff tear" only in his post op dx. And someone in the op note he'll state when/where the accident happened. I'm having difficulty figuring out if I should use SPRAIN S43.42-- sprain of rotator cuff capsule or STRAIN S46.01-- strain of muscle(s) and tendon(s) of the rotator cuff of shoulder.
Here's an example of one of our operative notes.
PREOPERATIVE DIAGNOSES: Left shoulder rotator cuff tear with AC arthrosis.
POSTOPERATIVE DIAGNOSES: Left shoulder rotator cuff tear with AC arthrosis with partial thickness biceps tearing and intraarticular synovitis.
PROCEDURES PERFORMED:
1. Left shoulder examination under anesthesia.
2. Left shoulder diagnostic arthroscopy with debridement.
3. Left shoulder arthroscopic subacromial decompression.
4. Left shoulder arthroscopic distal clavicle excision.
5. Left shoulder arthroscopic rotator cuff repair, full thickness.
SURGEON: BLANK
ASSISTANT SURGEON: BLANK
ANESTHESIA: General.
ANESTHESIOLOGIST: BLANK
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DISPOSITION: To the recovery room, then home when stable.
INDICATIONS: This is a 52-year-old female, who for a number of months, is status post an industrial
injury, complaining of pain and weakness in the left shoulder. An MRI consistent with a full-thickness
rotator cuff tear. After lengthy nonoperative care, the patient opted for surgical intervention.
EXAMINATION UNDER ANESTHESIA: Full internal and external rotation. She lacks about the last
10 to 15-degrees of full forward flexion with the arm slightly externally rotated. Manipulation was not
performed.
ARTHROSCOPIC FINDINGS: Glenoid and humeral head articular surfaces were normal. Inferior
glenohumeral ligament was normal. Axillary recess and posterior labrum was normal. Biceps tendon did
reveal some degeneration just as the biceps exited the shoulder prior to entering the intertubercular
groove. This was directly exposed from the subacromial space and was likely significantly impinged by a
large type III anterior acromion.
There was a full-thickness rotator cuff of the supraspinatus with the subscapularis out to its insertion
intact. Bursoscopy revealed dense fibrous bursal tissue, type III acromion, and a full-thickness
supraspinatus rotator cuff tear extending anterior right up to the exposed biceps tendon.
PROCEDURE: The patient was brought to the operating room, placed supine on the OR table. General
anesthesia induced smoothly. A preoperative interscalene block was requested and performed by
Dr. BLANK. The patient was placed into the beachchair position using strict spinal precautions. A timeout
was called confirming the correct patient, side, site, procedure, and the patient receiving preoperative
antibiotics. The left shoulder was sterilely prepped and draped. Standard posterior portal was made and
then using a spinal needle, an anterior portal was made. The arthroscope and probe were introduced and
all the above structures were noted and probed. Next, with a full-radius resector, the synovitis in the
anterior aspect of the shoulder was debrided as was the rotator cuff tear to better visualize the rotator cuff
footprint. Also with the biceps pulled into the shoulder, there was some degenerative tearing of the
biceps, though 80-90% of thickness of the biceps still intact. This was gently debrided only of unstable
tissue. Next, all instruments were placed into the subacromial space. An accessory anterolateral portal
was made. A subacromial decompression was done in the standard fashion using a power bur from the
anterolateral portal and then coming in from posterior to use a cutting block technique to flatten the
acromion to a flat type I acromion markedly increasing the subacromial space. Next, with the same bur, a
distal clavicle excision was performed, taking about 5 mm of the distal clavicle and about 5 mm of medial
acromion, also any downgoing spurs underneath the distal clavicle were removed as were downgoing
spurs about the median acromion. The clavicle was noted to be completely stable after debridement.
Next, the rotator cuff was grasped. There were noted to be horizontal laminations with a large superficial
and deep layer of rotator cuff tissue. Great care was taken over the biceps tendon when passing any
sutures or examining the rotator cuff and the rotator cuff was essentially in a large crescent tear with one
apex slightly posterior ward and was quite mobile, though was further mobilized with some blunt
dissection and dissection with an elevator. Next, the rotator cuff footprint right up to the biceps tendon
was debrided from the articular surface out to the greater tuberosity and to more healthy tissue in the
infraspinatus. This was just debrided down to bleeding cortical bone.
Next, two 4.75 x 19.1 mm BioComposite SwiveLocks loaded with FiberTape were placed evenly just off
the articular surface. Two of the tapes were passed in the anterior aspect of the crescent tear as well as
two of the FiberWires. All sutures once passed were taken out the anterior portal. A second posterior
anchor was placed and the two tapes were brought up with one on either side of the small radial tear
posterior ward, so as to close the small radial tear. The deep core sutures were removed. Next, the entire
rotator cuff footprint was trephinated with 1 mm K-wire with good extrusion of marrow component.
Next, with the arm abducted, the anterior of both FiberTapes and one of the FiberWire knot was taken
anterior for the lateral row just posterior to the intertubercular groove and secondarily fixated with the
arm in abduction with a 5.5 x 19.1 mm BioComposite SwiveLock. The remainder of the sutures were
taken posterior with the same repair. The rotator cuff tissue completely covered the rotator cuff footprint
with healthy tendon. There were no excessive dog ears that required any treatment.
The arthroscope was placed back into the joint and there was noted to be good rotator cuff tissue coming
right up to the articular surface and no violation of the biceps.
Next, with power inflow and suction outflow, mechanical agitation, the shoulder was irrigated. All
instruments were removed. Each portal was closed with nylon and then the remainder of the Marcaine
with epinephrine was instilled into the subacromial space after okay by anesthesia. A sterile dressing was
applied followed by DonJoy UltraSling. The patient was taken out the beachchair position using strict
spinal precautions. She was awakened and taken to the recovery room in stable condition.
How do I chose a ICD-10 for the rotator cuff tear?
Here's an example of one of our operative notes.
PREOPERATIVE DIAGNOSES: Left shoulder rotator cuff tear with AC arthrosis.
POSTOPERATIVE DIAGNOSES: Left shoulder rotator cuff tear with AC arthrosis with partial thickness biceps tearing and intraarticular synovitis.
PROCEDURES PERFORMED:
1. Left shoulder examination under anesthesia.
2. Left shoulder diagnostic arthroscopy with debridement.
3. Left shoulder arthroscopic subacromial decompression.
4. Left shoulder arthroscopic distal clavicle excision.
5. Left shoulder arthroscopic rotator cuff repair, full thickness.
SURGEON: BLANK
ASSISTANT SURGEON: BLANK
ANESTHESIA: General.
ANESTHESIOLOGIST: BLANK
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DISPOSITION: To the recovery room, then home when stable.
INDICATIONS: This is a 52-year-old female, who for a number of months, is status post an industrial
injury, complaining of pain and weakness in the left shoulder. An MRI consistent with a full-thickness
rotator cuff tear. After lengthy nonoperative care, the patient opted for surgical intervention.
EXAMINATION UNDER ANESTHESIA: Full internal and external rotation. She lacks about the last
10 to 15-degrees of full forward flexion with the arm slightly externally rotated. Manipulation was not
performed.
ARTHROSCOPIC FINDINGS: Glenoid and humeral head articular surfaces were normal. Inferior
glenohumeral ligament was normal. Axillary recess and posterior labrum was normal. Biceps tendon did
reveal some degeneration just as the biceps exited the shoulder prior to entering the intertubercular
groove. This was directly exposed from the subacromial space and was likely significantly impinged by a
large type III anterior acromion.
There was a full-thickness rotator cuff of the supraspinatus with the subscapularis out to its insertion
intact. Bursoscopy revealed dense fibrous bursal tissue, type III acromion, and a full-thickness
supraspinatus rotator cuff tear extending anterior right up to the exposed biceps tendon.
PROCEDURE: The patient was brought to the operating room, placed supine on the OR table. General
anesthesia induced smoothly. A preoperative interscalene block was requested and performed by
Dr. BLANK. The patient was placed into the beachchair position using strict spinal precautions. A timeout
was called confirming the correct patient, side, site, procedure, and the patient receiving preoperative
antibiotics. The left shoulder was sterilely prepped and draped. Standard posterior portal was made and
then using a spinal needle, an anterior portal was made. The arthroscope and probe were introduced and
all the above structures were noted and probed. Next, with a full-radius resector, the synovitis in the
anterior aspect of the shoulder was debrided as was the rotator cuff tear to better visualize the rotator cuff
footprint. Also with the biceps pulled into the shoulder, there was some degenerative tearing of the
biceps, though 80-90% of thickness of the biceps still intact. This was gently debrided only of unstable
tissue. Next, all instruments were placed into the subacromial space. An accessory anterolateral portal
was made. A subacromial decompression was done in the standard fashion using a power bur from the
anterolateral portal and then coming in from posterior to use a cutting block technique to flatten the
acromion to a flat type I acromion markedly increasing the subacromial space. Next, with the same bur, a
distal clavicle excision was performed, taking about 5 mm of the distal clavicle and about 5 mm of medial
acromion, also any downgoing spurs underneath the distal clavicle were removed as were downgoing
spurs about the median acromion. The clavicle was noted to be completely stable after debridement.
Next, the rotator cuff was grasped. There were noted to be horizontal laminations with a large superficial
and deep layer of rotator cuff tissue. Great care was taken over the biceps tendon when passing any
sutures or examining the rotator cuff and the rotator cuff was essentially in a large crescent tear with one
apex slightly posterior ward and was quite mobile, though was further mobilized with some blunt
dissection and dissection with an elevator. Next, the rotator cuff footprint right up to the biceps tendon
was debrided from the articular surface out to the greater tuberosity and to more healthy tissue in the
infraspinatus. This was just debrided down to bleeding cortical bone.
Next, two 4.75 x 19.1 mm BioComposite SwiveLocks loaded with FiberTape were placed evenly just off
the articular surface. Two of the tapes were passed in the anterior aspect of the crescent tear as well as
two of the FiberWires. All sutures once passed were taken out the anterior portal. A second posterior
anchor was placed and the two tapes were brought up with one on either side of the small radial tear
posterior ward, so as to close the small radial tear. The deep core sutures were removed. Next, the entire
rotator cuff footprint was trephinated with 1 mm K-wire with good extrusion of marrow component.
Next, with the arm abducted, the anterior of both FiberTapes and one of the FiberWire knot was taken
anterior for the lateral row just posterior to the intertubercular groove and secondarily fixated with the
arm in abduction with a 5.5 x 19.1 mm BioComposite SwiveLock. The remainder of the sutures were
taken posterior with the same repair. The rotator cuff tissue completely covered the rotator cuff footprint
with healthy tendon. There were no excessive dog ears that required any treatment.
The arthroscope was placed back into the joint and there was noted to be good rotator cuff tissue coming
right up to the articular surface and no violation of the biceps.
Next, with power inflow and suction outflow, mechanical agitation, the shoulder was irrigated. All
instruments were removed. Each portal was closed with nylon and then the remainder of the Marcaine
with epinephrine was instilled into the subacromial space after okay by anesthesia. A sterile dressing was
applied followed by DonJoy UltraSling. The patient was taken out the beachchair position using strict
spinal precautions. She was awakened and taken to the recovery room in stable condition.
How do I chose a ICD-10 for the rotator cuff tear?
