cynthiag14
Contributor
Hello,
I am looking for feedback on a sx. I am thinking to bill 29999 and deciding which CPT is best to compare to out of 29823, 29826, 29827 - thank you!
Operative report:
The patient was met in the preop holding area where informed consent was reviewed and the operative site was marked. He underwent regional anesthesia with the anesthesia team. She was transferred to the operating room where general anesthesia was induced. The patient was then positioned in beach chair position with all areas of bony prominence well padded. She received a dose of IV antibiotics. The operative upper extremity was prepped and draped in standard sterile fashion. A surgical time-out was performed.
Attention was turned towards the shoulder. A standard posterior arthroscopic portal was established for viewing. An anterior portal was immediately established through the rotator interval. Diagnostic arthroscopy was undertaken. The cartilage surfaces on the glenoid and humerus were marked by chondral fraying and grade 2 changes. There was complete tear of the long head of the biceps tendon with retraction. There was fraying of the superior, posterior, and anterior labrum without frank detachment. Subscapularis tendon was torn and retracted at least 2 cm at its upper border. There was no evidence of loose bodies. From the glenohumeral joint, there appeared to be a rotator cuff tear involving supraspinatus with extension into the infraspinatus. The supraspinatus tendon was visualized medial to the superior glenoid. Tendon was very poor quality. Mobilization was attempted with maximal mobilization to about 1 cm lateral to the glenoid rim. An arthroscopic shaver was utilized to debride anterior, superior, posterior, and inferior labral tearing. Synovium in the rotator interval and anterior capsule was debrided. Chondroplasty was undertaken of the frayed chondral edges.
Attention was then turned to the torn subscapularis tendon. A #2 FiberTape loop was passed through the most distal healthy-appearing subscapularis tendon, again about 2 cm retracted from the anatomic footprint. A grasping, locking construct was obtained. This was placed through a SwiveLock anchor which was placed in standard fashion at the anatomic footprint. Prior to final anchor placement, the suture was tensioned with restoration of the anatomic alignment. The sliding stitch from the anchor was additionally placed just medial to the extent suture and tied using the arthroscopic knot pusher for additional stability. Multiple arthroscopic photos were taken and added to the patient's medical record.
The arthroscope was then removed from the glenohumeral joint and redirected in the subacromial space. A lateral portal was established using spinal needle localization. A subacromial bursectomy was undertaken using an arthroscopic shaver and an electrocautery device. The CA ligament was mildly frayed and was gently debrided. Bursal side of the rotator cuff was evaluated. There was again noted a complete tear of the supraspinatus tendon. The tendon was retracted medial to the glenoid. A grasper was used to attempt mobilization of the tendon. There was noted to be extensive delamination of the tendon and little to no excursion, again no more than 1 cm lateral to the glenoid rim. The Stryker InSpace balloon was then sized for a small. It was inserted through the lateral portal and inflated with saline under arthroscopic visualization. The inserter handle was then removed and visual confirmation was obtained of plug placement. Multiple arthroscopic images were obtained and added to the patient was medical record. Portal sites were closed with 4-0 nylon suture. A sterile dressing was placed of Xeroform, dry gauze, ABD and foam tape. The operative extremity was placed in a sling. The patient was then extubated and transferred to the recovery room in stable condition.
I am looking for feedback on a sx. I am thinking to bill 29999 and deciding which CPT is best to compare to out of 29823, 29826, 29827 - thank you!
Operative report:
The patient was met in the preop holding area where informed consent was reviewed and the operative site was marked. He underwent regional anesthesia with the anesthesia team. She was transferred to the operating room where general anesthesia was induced. The patient was then positioned in beach chair position with all areas of bony prominence well padded. She received a dose of IV antibiotics. The operative upper extremity was prepped and draped in standard sterile fashion. A surgical time-out was performed.
Attention was turned towards the shoulder. A standard posterior arthroscopic portal was established for viewing. An anterior portal was immediately established through the rotator interval. Diagnostic arthroscopy was undertaken. The cartilage surfaces on the glenoid and humerus were marked by chondral fraying and grade 2 changes. There was complete tear of the long head of the biceps tendon with retraction. There was fraying of the superior, posterior, and anterior labrum without frank detachment. Subscapularis tendon was torn and retracted at least 2 cm at its upper border. There was no evidence of loose bodies. From the glenohumeral joint, there appeared to be a rotator cuff tear involving supraspinatus with extension into the infraspinatus. The supraspinatus tendon was visualized medial to the superior glenoid. Tendon was very poor quality. Mobilization was attempted with maximal mobilization to about 1 cm lateral to the glenoid rim. An arthroscopic shaver was utilized to debride anterior, superior, posterior, and inferior labral tearing. Synovium in the rotator interval and anterior capsule was debrided. Chondroplasty was undertaken of the frayed chondral edges.
Attention was then turned to the torn subscapularis tendon. A #2 FiberTape loop was passed through the most distal healthy-appearing subscapularis tendon, again about 2 cm retracted from the anatomic footprint. A grasping, locking construct was obtained. This was placed through a SwiveLock anchor which was placed in standard fashion at the anatomic footprint. Prior to final anchor placement, the suture was tensioned with restoration of the anatomic alignment. The sliding stitch from the anchor was additionally placed just medial to the extent suture and tied using the arthroscopic knot pusher for additional stability. Multiple arthroscopic photos were taken and added to the patient's medical record.
The arthroscope was then removed from the glenohumeral joint and redirected in the subacromial space. A lateral portal was established using spinal needle localization. A subacromial bursectomy was undertaken using an arthroscopic shaver and an electrocautery device. The CA ligament was mildly frayed and was gently debrided. Bursal side of the rotator cuff was evaluated. There was again noted a complete tear of the supraspinatus tendon. The tendon was retracted medial to the glenoid. A grasper was used to attempt mobilization of the tendon. There was noted to be extensive delamination of the tendon and little to no excursion, again no more than 1 cm lateral to the glenoid rim. The Stryker InSpace balloon was then sized for a small. It was inserted through the lateral portal and inflated with saline under arthroscopic visualization. The inserter handle was then removed and visual confirmation was obtained of plug placement. Multiple arthroscopic images were obtained and added to the patient was medical record. Portal sites were closed with 4-0 nylon suture. A sterile dressing was placed of Xeroform, dry gauze, ABD and foam tape. The operative extremity was placed in a sling. The patient was then extubated and transferred to the recovery room in stable condition.
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