cwilson3333
Expert
Would like an opinion of the coding on this shoulder surgery
OPERATION PERFORED: Arthroscopy left shoulder, joint debridement, labral debridement, acromioplasty, and proximal biceps tenodesis
PREOPERATIE DX; Biceps labral dysfunction, rotator cuff dysfunction, impingement shoulder
POSTOP DIX: Impingement syndrome, high-grade tear of labrum superiorly, posteriorly with sub acromial spur shoulder
DESCRIPTION OF PROCEDURE: The patient was brought in the operative theater, placed in supine position. Was given general anesthetic. He had Ancef intravenously. The beach chair was elevated to 60 degrees. The shoulder was examined. He had a good range of motion with no instability.
Attached to the spider. Landmarks were marked out. Three portals were made, posterior, lateral, and an anterior portal. Scope introduced into glenohumeral joint. Articularly surfaces had mild chondromalacia changes. The labrum was torn posterior at the superior half above the equator. The entire superior part, extending anteriorly. This extended to the biceps tendon. Labral debridement was done and then the biceps was taken down. The rotator cuff looked fine, subscap looked fine, rotator interval looked good.
The scope was introduced into the subacromial space, which was very tight. Acromioplasty was done for 4-5 mm. CA ligament resection was done in usual manner. The superior rotator cuff looked great. A subacromial bursal debridement was performed at the same time.
The lateral incision was extended to 3 cm and dissection was carried down to the biceps sheath. The biceps was delivered into the wound. A tiger loop was attached to it in the usual manner. The tiger loop was placed into a proximal biceps tenodesis TightRope. Unicortical fixation was done in usual manner with a drill point and then it was buried down into the head. It gave a nice, tight biceps tenodesis. Irrigated copiously with sterile saline.
Closure was done in the usual manner. It was dressed and wrapped. No complications.
I am looking at 23430
29823
29826
Opinions, please. Am I coding correctly?
OPERATION PERFORED: Arthroscopy left shoulder, joint debridement, labral debridement, acromioplasty, and proximal biceps tenodesis
PREOPERATIE DX; Biceps labral dysfunction, rotator cuff dysfunction, impingement shoulder
POSTOP DIX: Impingement syndrome, high-grade tear of labrum superiorly, posteriorly with sub acromial spur shoulder
DESCRIPTION OF PROCEDURE: The patient was brought in the operative theater, placed in supine position. Was given general anesthetic. He had Ancef intravenously. The beach chair was elevated to 60 degrees. The shoulder was examined. He had a good range of motion with no instability.
Attached to the spider. Landmarks were marked out. Three portals were made, posterior, lateral, and an anterior portal. Scope introduced into glenohumeral joint. Articularly surfaces had mild chondromalacia changes. The labrum was torn posterior at the superior half above the equator. The entire superior part, extending anteriorly. This extended to the biceps tendon. Labral debridement was done and then the biceps was taken down. The rotator cuff looked fine, subscap looked fine, rotator interval looked good.
The scope was introduced into the subacromial space, which was very tight. Acromioplasty was done for 4-5 mm. CA ligament resection was done in usual manner. The superior rotator cuff looked great. A subacromial bursal debridement was performed at the same time.
The lateral incision was extended to 3 cm and dissection was carried down to the biceps sheath. The biceps was delivered into the wound. A tiger loop was attached to it in the usual manner. The tiger loop was placed into a proximal biceps tenodesis TightRope. Unicortical fixation was done in usual manner with a drill point and then it was buried down into the head. It gave a nice, tight biceps tenodesis. Irrigated copiously with sterile saline.
Closure was done in the usual manner. It was dressed and wrapped. No complications.
I am looking at 23430
29823
29826
Opinions, please. Am I coding correctly?