dyoungberg
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Good Morning All,
I am having trouble coding the following Op Report. Any thoughts would be greatly appreciated.
POSTOP DIAGNOSIS: LEFT SHOULDER SLAP TEAR AND IMPINGEMENT
PROCEDURE:
1. LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY
2. LEFT SHOULDER ARTHROSCOPIC SUBACROMIAL DECOMPRESSION WITH ACROMIOPLASTY
3. LEFT SHOULDER ARTHROSCOPIC DEBRIDEMENT OF SLAP TEAR
ANESTHESIA: GENERAL
IMPLANT: NONE
CONDITION: PATIENT EXTUBATED AND TAKEN TO RECOVERY IN GOOD CONDITION
INTRAOPERATIVE FINDINGS:
1. Rotator interval without any evidence of injury.
2. Anterior posterior labrum intact.
3. Superior labrum with evidence of a type I SLAP tear without destabilization of biceps anchor.
4. Mild amount of extra articular biceps tendinopathy with fraying of the superior glenohumeral ligament.
5. Subscapularis intact.
6. Buford complex noted.
7. Axillary recess free and clear of any loose bodies.
8. Glenohumeral joint without any evidence of chondrosis.
9. Posterior mid and anterior rotator cuff intact.
10. Moderate amount of subacromial bursitis.
11. Type III hooked acromion.
12. Adequate subacromial decompression obtained.
INDICATIONS FOR PROCEDURE: Mandi Turner is a 27 year old female with a long history of left shoulder pain, unresponsive to nonoperative treatments. The risks and benefits of surgical management were discussed with the patient and she was given the opportunity to ask questions regarding her treatment plan. When her questions were answered to her satisfaction, she elected to proceed with surgery and signed informed consent.
PROCEDURE IN DETAIL: The patient was greeted in the preoperative holding area where the left shoulder was correctly identified and initialed as the surgical site. She was then administered an interscalene block by anesthesia for postoperative pain management. Next, she was brought back to the operating room for the procedure where she was placed supine on the OR table and appropriate cardiopulmonary monitoring devices were connected. 1 gram Ancef was given IV. SCD's were placed on both lower extremities. Bony prominences were well padded. She was then administered general anesthesia and intubated. The left shoulder was examined under anesthesia and found to have a ROM of 180 degrees of forward flexion and abduction, 90 degrees external rotation with the arm at the side, 90 degrees external rotation with the arm abducted, and 90 degrees internal rotation with the arm abducted. These findings were all symmetric to the unaffected side. Next, the patient was sat up in the beach chair position with her head held in a well-padded neutral fashion and the LUE was prepped and draped in a standard surgical fashion. Appropriate surgical timeout was performed to confirm the patient as Mandi Turner and to confirm the operative site as the left shoulder. Bony landmarks and incisions were drawn on the skin and the subcutaneous tissue was infiltrated with approximately 8 cc 0.25% Marcaine w/epinephrine.
A posterior portal was used to gain access into the joint and diagnostic arthroscopy began with inspection of the rotator interval which was atraumatic in nature. We established an anterior portal under direct visualization and inserted an arthroscopic probe into the glenohumeral joint and evaluated the anterior inferior and posterior labrums which were all intact without any evidence of fraying or degeneration. The superior labrum had synovitis associated with it, in addition to some fraying, consistent with a type I SLAP tear. No destabilization of the biceps anchor was noted and the extra articular portion of the biceps tendon was brought into the joint and there was mild reactive lipstick synovitis extending out onto its extra articular portion without any evidence of tearing. The subscapularis was evaluated in internal and external rotation and noted to be intact without any detachment. There was fraying to the superior glenohumeral ligament and a Buford complex in the anterior superior aspect of the shoulder. No chondral injury was noted to the glenoid or the humerus and the axillary recess was free and clear of any loose bodies or adhesions. The posterior, mid and anterior rotator cuff were intact without any evidence of injury. Next, we inserted our arthroscopic shaver and debrided our SLAP tear and our frayed SGHL. When this was completed, we removed our instruments from the glenohumeral joint and then proceeded into the subacromial space. Once inside the subacromial space we encountered a fairly moderately significant subacromial and subdeltoid bursitis and a complete bursectomy was performed in both the subdeltoid and subacromial recesses and spaces. We established a lateral portal under direct visualization and inserted an arthroscopic ablation device and then outlined the undersurface of the acromion. A type III hook configuration was noted with impingement and a decrease of the acromial humeral interval and in two planes an arthroscopic bur was used to convert this type III configuration to a type I configuration creating adequate decompression. The rotator cuff was inspected on the superior aspect and noted to be without any evidence of trauma or degeneration. At this point we then removed our instruments from the subacromial space and injected an additional 10-12 cc 0.25% Marcaine w/epinephrine.
We closed all incisions with 4-0 Monocryl suture in the subcuticular layer and used Dermabond to approximate the skin. A sterile dressing was then placed and the drapes were removed.
The patient was then awakened, extubated, and taken to the recovery room in good condition.
Sponge and instrument counts were correct x two at the end of case.
There were no known orthopedic complications for this case.
POSTOPERATIVE PLAN: The patient will be discharged home pending passing postanesthesia criteria. Follow up in two weeks for a wound check. She will begin physical therapy per postoperative protocol.
Code 29826 - Subacromial Decompression is now an add on code. I was thinking 29822 & 29826 would cover this procedure. However my coding software tells me 29822 is considered to be part of 29826. Any ideas on how I should code this?
Thanks much!
I am having trouble coding the following Op Report. Any thoughts would be greatly appreciated.
POSTOP DIAGNOSIS: LEFT SHOULDER SLAP TEAR AND IMPINGEMENT
PROCEDURE:
1. LEFT SHOULDER DIAGNOSTIC ARTHROSCOPY
2. LEFT SHOULDER ARTHROSCOPIC SUBACROMIAL DECOMPRESSION WITH ACROMIOPLASTY
3. LEFT SHOULDER ARTHROSCOPIC DEBRIDEMENT OF SLAP TEAR
ANESTHESIA: GENERAL
IMPLANT: NONE
CONDITION: PATIENT EXTUBATED AND TAKEN TO RECOVERY IN GOOD CONDITION
INTRAOPERATIVE FINDINGS:
1. Rotator interval without any evidence of injury.
2. Anterior posterior labrum intact.
3. Superior labrum with evidence of a type I SLAP tear without destabilization of biceps anchor.
4. Mild amount of extra articular biceps tendinopathy with fraying of the superior glenohumeral ligament.
5. Subscapularis intact.
6. Buford complex noted.
7. Axillary recess free and clear of any loose bodies.
8. Glenohumeral joint without any evidence of chondrosis.
9. Posterior mid and anterior rotator cuff intact.
10. Moderate amount of subacromial bursitis.
11. Type III hooked acromion.
12. Adequate subacromial decompression obtained.
INDICATIONS FOR PROCEDURE: Mandi Turner is a 27 year old female with a long history of left shoulder pain, unresponsive to nonoperative treatments. The risks and benefits of surgical management were discussed with the patient and she was given the opportunity to ask questions regarding her treatment plan. When her questions were answered to her satisfaction, she elected to proceed with surgery and signed informed consent.
PROCEDURE IN DETAIL: The patient was greeted in the preoperative holding area where the left shoulder was correctly identified and initialed as the surgical site. She was then administered an interscalene block by anesthesia for postoperative pain management. Next, she was brought back to the operating room for the procedure where she was placed supine on the OR table and appropriate cardiopulmonary monitoring devices were connected. 1 gram Ancef was given IV. SCD's were placed on both lower extremities. Bony prominences were well padded. She was then administered general anesthesia and intubated. The left shoulder was examined under anesthesia and found to have a ROM of 180 degrees of forward flexion and abduction, 90 degrees external rotation with the arm at the side, 90 degrees external rotation with the arm abducted, and 90 degrees internal rotation with the arm abducted. These findings were all symmetric to the unaffected side. Next, the patient was sat up in the beach chair position with her head held in a well-padded neutral fashion and the LUE was prepped and draped in a standard surgical fashion. Appropriate surgical timeout was performed to confirm the patient as Mandi Turner and to confirm the operative site as the left shoulder. Bony landmarks and incisions were drawn on the skin and the subcutaneous tissue was infiltrated with approximately 8 cc 0.25% Marcaine w/epinephrine.
A posterior portal was used to gain access into the joint and diagnostic arthroscopy began with inspection of the rotator interval which was atraumatic in nature. We established an anterior portal under direct visualization and inserted an arthroscopic probe into the glenohumeral joint and evaluated the anterior inferior and posterior labrums which were all intact without any evidence of fraying or degeneration. The superior labrum had synovitis associated with it, in addition to some fraying, consistent with a type I SLAP tear. No destabilization of the biceps anchor was noted and the extra articular portion of the biceps tendon was brought into the joint and there was mild reactive lipstick synovitis extending out onto its extra articular portion without any evidence of tearing. The subscapularis was evaluated in internal and external rotation and noted to be intact without any detachment. There was fraying to the superior glenohumeral ligament and a Buford complex in the anterior superior aspect of the shoulder. No chondral injury was noted to the glenoid or the humerus and the axillary recess was free and clear of any loose bodies or adhesions. The posterior, mid and anterior rotator cuff were intact without any evidence of injury. Next, we inserted our arthroscopic shaver and debrided our SLAP tear and our frayed SGHL. When this was completed, we removed our instruments from the glenohumeral joint and then proceeded into the subacromial space. Once inside the subacromial space we encountered a fairly moderately significant subacromial and subdeltoid bursitis and a complete bursectomy was performed in both the subdeltoid and subacromial recesses and spaces. We established a lateral portal under direct visualization and inserted an arthroscopic ablation device and then outlined the undersurface of the acromion. A type III hook configuration was noted with impingement and a decrease of the acromial humeral interval and in two planes an arthroscopic bur was used to convert this type III configuration to a type I configuration creating adequate decompression. The rotator cuff was inspected on the superior aspect and noted to be without any evidence of trauma or degeneration. At this point we then removed our instruments from the subacromial space and injected an additional 10-12 cc 0.25% Marcaine w/epinephrine.
We closed all incisions with 4-0 Monocryl suture in the subcuticular layer and used Dermabond to approximate the skin. A sterile dressing was then placed and the drapes were removed.
The patient was then awakened, extubated, and taken to the recovery room in good condition.
Sponge and instrument counts were correct x two at the end of case.
There were no known orthopedic complications for this case.
POSTOPERATIVE PLAN: The patient will be discharged home pending passing postanesthesia criteria. Follow up in two weeks for a wound check. She will begin physical therapy per postoperative protocol.
Code 29826 - Subacromial Decompression is now an add on code. I was thinking 29822 & 29826 would cover this procedure. However my coding software tells me 29822 is considered to be part of 29826. Any ideas on how I should code this?
Thanks much!