See operative report below. I coded CPT codes: 29826-RT-59, 23410-RT. Code 29826 is an add on code and needs either CPT 29806-29825, 29827, or 29828. I've looked at the description of these codes and I don't believe any of these were done. Does anyone have any suggestions?
Thanks,
Deidre Johnson, CPC-A
PREOPERATIVE DIAGNOSIS:
Rotator cuff tear right shoulder
POSTOPERATIVE DIAGNOSIS:
High grade partial thickness tear right supraspinatus
PROCEDURE:
Right shoulder arthroscopy, arthroscopic subacromial decompression, mini open
rotator cuff repair
ANESTHESIA:
General with supraclavicular block, ultrasound guided
INDICATION:
The patient is a 69-year-old female with signs and symptoms consistent with a
rotator cuff tear. She has MRI evidence of at least a high grade partial
thickness tear of the supraspinatus at its insertion. Treatment options were
discussed including risks and benefits of operative intervention. After
informed consent, she is brought to the operating room for the following
procedure.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and placed in the supine position.
After induction of general anesthesia and installation of a supraclavicular
nerve block, she was placed in a semi sitting position and her right shoulder
was prepped and draped in the usual sterile fashion. Examination under
anesthesia showed no instability or loss of motion. We began by introducing
the arthroscope through a stab incision in the posterior position into the
glenohumeral joint. Her articular surfaces were intact as was the glenoid
labrum, biceps anchor and subscapularis tendon. We visualized the rotator cuff
at its insertion and there was an obvious, at least high grade, partial
thickness tear of the supraspinatus. It involved approximately 80 to 90% of
the footprint. We proceeded to the subacromial position, established a lateral
portal and performed an anterior acromioplasty. We confirmed resection of the
anterior lateral corner of the acromion with a spinal needle and used this to
guide placement of an incision. The skin was incised approximately 3 or 4 cm
off the anterior lateral corner of the acromion. The deltoid was split in line
with its fibers and a self retaining retractor placed. We completed bursectomy
as necessary to visualize the rotator cuff and palpated the underlying greater
tuberosity. The intact fibers overlying the attenuated tendon on the greater
tuberosity were incised and we identified frayed torn rotator cuff inferior to
this position. We split the insertion off the greater tuberosity elevating the
edges until we could debride the rotator cuff back to full thickness edges. We
debrided the underlying bone of the greater tuberosity with a rongeur
representing the footprint of the supraspinatus. At this point, we utilized a
6.5 screw in anchor placing a single limb of each of the two sutures in the
anterior and posterior edges of the now V shaped tear. As we tied the sutures,
it advanced the cuff slightly laterally and the edges together. The repair was
stable with the arm at the side. We irrigated and closed deltoid fascia with
#0 Vicryl, subcutaneous with #2-0 Vicryl, skin was closed with #4-0 Vicryl in
subcuticular fashion. Steri strips were applied as well as a dry sterile
lightly compressive dressing. She was placed in a sling and taken to the
recovery room in stable condition.
Thanks,
Deidre Johnson, CPC-A
PREOPERATIVE DIAGNOSIS:
Rotator cuff tear right shoulder
POSTOPERATIVE DIAGNOSIS:
High grade partial thickness tear right supraspinatus
PROCEDURE:
Right shoulder arthroscopy, arthroscopic subacromial decompression, mini open
rotator cuff repair
ANESTHESIA:
General with supraclavicular block, ultrasound guided
INDICATION:
The patient is a 69-year-old female with signs and symptoms consistent with a
rotator cuff tear. She has MRI evidence of at least a high grade partial
thickness tear of the supraspinatus at its insertion. Treatment options were
discussed including risks and benefits of operative intervention. After
informed consent, she is brought to the operating room for the following
procedure.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and placed in the supine position.
After induction of general anesthesia and installation of a supraclavicular
nerve block, she was placed in a semi sitting position and her right shoulder
was prepped and draped in the usual sterile fashion. Examination under
anesthesia showed no instability or loss of motion. We began by introducing
the arthroscope through a stab incision in the posterior position into the
glenohumeral joint. Her articular surfaces were intact as was the glenoid
labrum, biceps anchor and subscapularis tendon. We visualized the rotator cuff
at its insertion and there was an obvious, at least high grade, partial
thickness tear of the supraspinatus. It involved approximately 80 to 90% of
the footprint. We proceeded to the subacromial position, established a lateral
portal and performed an anterior acromioplasty. We confirmed resection of the
anterior lateral corner of the acromion with a spinal needle and used this to
guide placement of an incision. The skin was incised approximately 3 or 4 cm
off the anterior lateral corner of the acromion. The deltoid was split in line
with its fibers and a self retaining retractor placed. We completed bursectomy
as necessary to visualize the rotator cuff and palpated the underlying greater
tuberosity. The intact fibers overlying the attenuated tendon on the greater
tuberosity were incised and we identified frayed torn rotator cuff inferior to
this position. We split the insertion off the greater tuberosity elevating the
edges until we could debride the rotator cuff back to full thickness edges. We
debrided the underlying bone of the greater tuberosity with a rongeur
representing the footprint of the supraspinatus. At this point, we utilized a
6.5 screw in anchor placing a single limb of each of the two sutures in the
anterior and posterior edges of the now V shaped tear. As we tied the sutures,
it advanced the cuff slightly laterally and the edges together. The repair was
stable with the arm at the side. We irrigated and closed deltoid fascia with
#0 Vicryl, subcutaneous with #2-0 Vicryl, skin was closed with #4-0 Vicryl in
subcuticular fashion. Steri strips were applied as well as a dry sterile
lightly compressive dressing. She was placed in a sling and taken to the
recovery room in stable condition.
