Shoulder sx??


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:eek: Can someone help me with the following operative report?

Postoperative dx:
1. Rotator cuff tear of rt shoulder
2. Long head biceps tear of rt shoulder

1. Arthroscopy of rt shoulder w/debridement
2. Open decompression acromioplasty
3. Open rotator cuff repair
4. Open biceps tenodesis

...posterior portal was injected w/10 ml Marcaine and epinephrine and then created w/a #11 blade. The arthroscope was introduced atraumatically into glenohumeral articulation w/a visualization in the anterior portal was created. Shoulder was examined anteriorly and then posteriorly w/the above noted findings. The shave was introduced anteriorly. The anterior labrum was debrided slightly. The biceps was carefully debrided as well and the full extent of the tearing was noted. Basket forceps was then introduced and the biceps was resected from the top the glenoid stabilizing the labral rim.

The arthroscope was withdrawn. An anterolateral incision was then made to the shoulder through skin into subcutaneous tissue where full thinckness flaps were raised medially and laterally. The anterolateral raphe of the deltoid was incised and taken off the anterior edge of the acromion, incorportating the superficial and the deep fascia. Easily, the biceps was indentified at this site. It was tagged at its resting margin and the tuberosity groove. Decortication and the keyhole was then performed within the bicipital groove. A whipstitch of the #2 braided suture was then passed through the long head of the biceps w/a modified Kessler stitch, incorporating the Stryker anchor anteriorly.

Tenodesis was performed, as then the leading edge of the rotator cuff was debrided to a healthier margin. Decortication of the tuberosity was performed and a second 5.0 anchor was then inserted. The rotator cuff was then reapproximated side to side at its apex and then reattached to the tuberosity w/the use of the 5.0 anchor and the double loaded sutures. A solid repair was noted w/o significant soft tissue or subacromial impingement. Irrigation was performed throughout. Acromioplasty was performed with an oscillating saw of a significant type 3 acromion. The wound was copiously irrigated w/saline post repair and the deltoid was reapproximated to the acromion incorporating the superficial and the deep fascia w/#1 Ethibond suture.....

Shoulders are very frustrating for me! Can anyone help me with this? Your help will be much appreciated!


True Blue
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I did not award the decompression (23130) because there was not enough documentation to support using the -59 modifier. The 29823 was iffy but I felt there was enough to support an appeal.

Cathy codes for a physician so I did not advise on the implants that I would have if it had been an ASC.