Our doctor performed right shoulder arthroscopy, arthroscopic debridement of labrum, rotator cuff debridement and tuberoplasty of the greater tuberosity of humerus and I am not sure how to code for the tuberoplasty?.
The description of the procedure is as follows:
The patient was induced under general anesthesia. Once the patient was asleep, the patient was placed in the lateral decubitus position. Care was taken to pad the bony prominences. Standard chlorhexidine prep was performed. The patient was placed in the lateral decubitus position. Standard draping for shoulder arthroplasty was performed. The arm was placed on Arthrex Star shoulder holder. Surgical time-out was performed identifying the patient, site, and surgery. A posterior portal was made. The joint was entered. There was a lot of synovitis. Synovectomy was performed. The labrum was frayed. The labral debridement was performed. The above findings were noted. There was significant chondromalacia, at least grade 3 throughout. More superiorly, massive tear of the supraspinatus and infraspinatus was noted. At this point, actually labral debridement was performed. I debrided the cuff. The edges had a lot of bad bursa, just really inflamed bursa. This was debrided. I also went to the space. I went down to the tuberosities. During abduction, I can see impingement of tuberosity on the acromions. At this point, I took a bur and did a tuberoplasty. I burred down the tuberosity, so that during maximum abduction, there was no longer impingement from the tuberosity and the acromion. I spent a lot of time cleaning up the scar tissue. Then, I removed the scope and injected with ropivacaine. The portals were closed. Sterile dressing was applied. The patient was taken to the recovery room in stable condition.
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