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Mini-open RCR with arthroscopic tenolysis of biceps tendon

  1. #1
    Default Mini-open RCR with arthroscopic tenolysis of biceps tendon
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    Need help with tenolysis of biceps tendon code. Would it be the unlisted code 29999? Please help!!

    Op Note:

    PREOPERATIVE DIAGNOSIS: Recurrent tear of left shoulder rotator cuff.

    POSTOPERATIVE DIAGNOSIS: Recurrent tear of left shoulder rotator cuff with biceps tendon tear and tendinopathy.

    PROCEDURE: Arthroscopy of the left shoulder with tenolysis of long head of the biceps tendon, débridement, and mini-open repair of the left rotator cuff.

    INDICATIONS: The patient is a 61-year-old male with a history of previous left shoulder rotator cuff repair, which was done approximately two years ago. He developed increasing pain and weakness of the shoulder with MRI again confirming evidence of recurrent tear of rotator cuff. He was admitted today for arthroscopy and debridement of the repair of the rotator cuff for treatment of the recurrent painful shoulder.

    PROCEDURE IN DETAIL: The patient was taken to the operating suite where he was kept supine on the operative table. He was given a general anesthetic. He was positioned in the beach chair position on the operative table. His left shoulder and arm were prepped with Betadine solution and draped in a sterile fashion. Upon completion of draping, the previous incision and protal sites were identified on the shoulder and used for introduction of the scope into the shoulder joint. The posterior portal was established with camera and inflow inserted through the posterior portal. The anterior portal was identified and used for exposure and probing of the shoulder joint. The patient was found to have significant fraying and tearing of the undersurface of the rotator cuff with full-thickness rotator cuff tear. He also had significant fraying and tearing of the long head of the biceps tendon.


    PROCEDURE IN DETAIL (CONT.): A shaver was used to débride the torn portion of tendon and after débridement, the patient was found to have significantly degreased tearing tendon remaining, involving greater than 30% of the long head of the biceps tendon because of the continued disease and to the long head of the tendon, it was elected to perform a biceps tenolysis where the long head of the tendon was released off of the superior attachment and the glenoid. Using the Mitek VAPR wand, the tendon was transected and the shaver was used to débride the snuff remaining. Further inspection of the shoulder revealed an intact glenohumeral surface and an intact labrum. There were no loose bodies seen in the head. There was radial fraying and tearing of the rotator cuff and a shaver was used to débride the rotator cuff from below and once débridement was completed, the scope was then placed from the posterior portal in the subacromial space where the distal bursa was resected to expose the full-thickness rotator cuff tear. A shaver was used to smooth the undersurface of the acromion, although his previous acromioplasty appeared to be adequate. The arthroscopic portion was then terminated and the lateral poral enlarged in a cranial direction, in line with the previous skin incision. The deltoid fiber was split in line with the skin incision to expose the subacromial space. The distal bursa was resected to expose the rotator cuff. The cuff was débrided. The patient was found to have a large rotator cuff tear extending medially towards the glenoid. The edge of the tear was débrided and the patient had sutures placed deep in the mid substance of the tear to repair the tear in a side-to-side fashion. The burr was used to create a bed of bleeding bone along the greater tuberosity and a Mitek 60.5-mm titanium suture anchor was placed in tuberosity. Double arms of the suture were passed through the rotator cuff. The sutured were tied, re-approximating the tear back to the tuberosity with good apposition and a lateral suture bridge was used to reinforce the repair using VERSALOK suture anchor. Following placement of the anchors and repair of the rotator cuff, inspection revealed good approximation and repair. The wound was then irrigated and closed. The 0 Vicryl suture was used to close the deltoid split with 2-0 Vicryl used in the subcutaneous tissues. Then, 0.5% Marcaine with epinephrine was used in the shoulder and subcutaneous tissues for postoperative pain control. A large bulky dressing was applied to the shoulder.

  2. #2
    unlisted with cross reference to 23405 is what I use (I did not read your report, just the question).
    Mary, CPC, CANPC, COSC

  3. Default
    Yep. The same...unlisted..29999...biceps release.

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