shoulder scope


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Hi, I feel that since there were multiple portals involved here, this would be coded 29822-RT, 29826. Does anyone this that this would be an over-code?


PRINCIPAL DIAGNOSIS: Right shoulder intra-articular rotator cuff tear with impingement.

PRINCIPLE PROCEDURE: Arthroscopy, arthroscopic intra-articular debridement, followed by subacromial decompression.

DESCRIPTION OF PROCEDURE: Patient site marked in the holding area. Time-out was done on patient entry into the room. Two grams of Ancef were given within 1 hour of the incision. All bony prominences were appropriately padded. Warm blankets and warm IV fluids used throughout the procedure to maintain optimum normothermia. Lidocaine 1% with 1:200,000 epinephrine solution was instilled in the intra-articular portion of the joint. The patient's right shoulder was then prepped and draped in the usual sterile fashion. Posterior portal was incised, inflow and scope inserted. The glenohumeral joint was inspected and probed. She was noted have a normal glenohumeral joint, normal subscap, normal biceps. She was noted to have some fraying, we estimated it to be about 10% of the rotator cuff supraspinatus insertion into the tuberosity. We placed the Synovator into the intra-articular portion to debride that out to make sure that the rest of the rotator cuff was stable and, after debriding that out, it was stable with good integrity of most of the cuff intact. We then went subacromially. She was noted to have a proliferative bursitis which we debrided. We decompressed the subacromial space, and took down an anterior hook of the acromion. She had good space in the AC joint, so we did not coplane or do an arthroscopic Mumford. We then copiously irrigated, closed with Prolene, we placed Toradol and Astramorph
in the shoulder for postop analgesia. Patient tolerated the procedure well and was taken to the recovery room in good condition. Sponge and needle counts were correct