Hello all! I have a shoulder surgery that I need help with, please. Here goes:
Description of Procedure: After informed consent was obtained the patient was taken to the operative suite and placed onto the operating table in the supine position. After successful induction of general endotracheal anesthetic, the patient was placed in a beach chair position with the right shoulder draped free from the lateral aspect of the operating table. The right shoulder was draped and prepped in normal sterile fashion. A standard posterior arthroscopic portal was created. Diagnostic arthroscopic camera was introduced into the glenohumeral space of the right shoulder through the posterior arthroscopic portal. Diagnostic arthroscopy was carried out in the glenohumeral space revealing a full thickness anterior glenoid labral tear, significant synovitis, full thickness supraspinatus tendon tear of the right shoulder. An arthroscopic anterior portal was created into the glenohumeral space of the right shoulder through the anterior/inferior arthroscopic portal and arthroscopic electrocautery unit was introduced. Synovectomy was carried out in the glenohumeral space of the right shoulder followed by anterior glenolabral reconstruction utilizing a juggernaut in a Tennessee slider knot configuation. Arthroscopic photographs were taken throughout the glenohumeral portion of the procedure and confirmed both diagnosis and completion of procedure. The glenohumeral space of the right shoulder was drained of irrigation fluid. Arthroscopic camera was redirected through the arthroscopic posterior portal into the subacromial space of the right shoulder. Anterolateral arthroscopic portal was created. Through the anterlateral arthroscopic portal, an arthroscopic elecgtrocautery unit was introduced into the subacromial space of the right shoulder. An arthroscopic subacromial bursectomy was carried out, revealing a large anterior acromial spur and significant degenerative changes of the inferior aspect of the acromioclavicular joint. An arthroscopic barrel bur was intermittendly introduced into the subacromial space of the right shoulder through the anterolateral and the anterior/inferior portals. Arthroscopic subacromial bursectomy and distal clavicle resection was carried out. Arthroscopic photographs were taken throughout the subacromial portion of the procedure. The subacromial space was drained of irrigation fluid. Arthroscopic instruments were removed in their entirely. Anterior, inferior, and posterior arthroscopic portals were reapproximated with surgical staples. The anterolateral arthroscopic portal was extended in a proximal direction to the anterolateral aspect of the acromion. The deltoid splitting subacromial approach was carried out to the right shoulder, revealing full thickness supraspinatus tendon tear. The full thickness supraspinatus tendon tear was sharply debrided with a 15 blade scalpel. A bleeding bony trough was created in the proximal aspect of the right proximal humerus near the greater tuberosity, double row rotator cuff repair was carried utilizing two 5.5 mm PEEK all-thread suture anchors medially and two 5.5 mm PEEK knotless suture anchors laterally. The shoulder was taken throught a passive range of motion and found to be no impingement upon the subacromial structures in the rotator cuff repair. Wounds were copiously irrigated. Deep and superficial fascia of the deltoid musculature was reapproximated with 1 Ethibond suture. Subcutaneous tissues were approximated with 2-0 running Vicryl suture. The skin was approximated with surgical staples. Local anesthestic was injected into the incision site for postoperative pain management. A sterile dressing was applied.
POSTOPERATIVE DIAGNOSIS: Rotator cuff arthropathy, acromioclavicular joing degenerative changes, and torn anterior glenoid labrum and torn supraspinatus tendon of right shoulder.
Doc coded this out as: 23420, 29807, 29826, 29824. Please give any thoughts or reasonings to help. I really appreciate any feedback.
Description of Procedure: After informed consent was obtained the patient was taken to the operative suite and placed onto the operating table in the supine position. After successful induction of general endotracheal anesthetic, the patient was placed in a beach chair position with the right shoulder draped free from the lateral aspect of the operating table. The right shoulder was draped and prepped in normal sterile fashion. A standard posterior arthroscopic portal was created. Diagnostic arthroscopic camera was introduced into the glenohumeral space of the right shoulder through the posterior arthroscopic portal. Diagnostic arthroscopy was carried out in the glenohumeral space revealing a full thickness anterior glenoid labral tear, significant synovitis, full thickness supraspinatus tendon tear of the right shoulder. An arthroscopic anterior portal was created into the glenohumeral space of the right shoulder through the anterior/inferior arthroscopic portal and arthroscopic electrocautery unit was introduced. Synovectomy was carried out in the glenohumeral space of the right shoulder followed by anterior glenolabral reconstruction utilizing a juggernaut in a Tennessee slider knot configuation. Arthroscopic photographs were taken throughout the glenohumeral portion of the procedure and confirmed both diagnosis and completion of procedure. The glenohumeral space of the right shoulder was drained of irrigation fluid. Arthroscopic camera was redirected through the arthroscopic posterior portal into the subacromial space of the right shoulder. Anterolateral arthroscopic portal was created. Through the anterlateral arthroscopic portal, an arthroscopic elecgtrocautery unit was introduced into the subacromial space of the right shoulder. An arthroscopic subacromial bursectomy was carried out, revealing a large anterior acromial spur and significant degenerative changes of the inferior aspect of the acromioclavicular joint. An arthroscopic barrel bur was intermittendly introduced into the subacromial space of the right shoulder through the anterolateral and the anterior/inferior portals. Arthroscopic subacromial bursectomy and distal clavicle resection was carried out. Arthroscopic photographs were taken throughout the subacromial portion of the procedure. The subacromial space was drained of irrigation fluid. Arthroscopic instruments were removed in their entirely. Anterior, inferior, and posterior arthroscopic portals were reapproximated with surgical staples. The anterolateral arthroscopic portal was extended in a proximal direction to the anterolateral aspect of the acromion. The deltoid splitting subacromial approach was carried out to the right shoulder, revealing full thickness supraspinatus tendon tear. The full thickness supraspinatus tendon tear was sharply debrided with a 15 blade scalpel. A bleeding bony trough was created in the proximal aspect of the right proximal humerus near the greater tuberosity, double row rotator cuff repair was carried utilizing two 5.5 mm PEEK all-thread suture anchors medially and two 5.5 mm PEEK knotless suture anchors laterally. The shoulder was taken throught a passive range of motion and found to be no impingement upon the subacromial structures in the rotator cuff repair. Wounds were copiously irrigated. Deep and superficial fascia of the deltoid musculature was reapproximated with 1 Ethibond suture. Subcutaneous tissues were approximated with 2-0 running Vicryl suture. The skin was approximated with surgical staples. Local anesthestic was injected into the incision site for postoperative pain management. A sterile dressing was applied.
POSTOPERATIVE DIAGNOSIS: Rotator cuff arthropathy, acromioclavicular joing degenerative changes, and torn anterior glenoid labrum and torn supraspinatus tendon of right shoulder.
Doc coded this out as: 23420, 29807, 29826, 29824. Please give any thoughts or reasonings to help. I really appreciate any feedback.