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op note

  1. #1
    Default op note
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    Procedure: Left shoulder arthroscopy with limited debridement of rotator cuff tear
    Left shoulderarthroscopic subcromial decompression with excision of acromiale

    The left upper extremity was prepped and draped in a sterile fashion. Standard anterior and posterior arthroscopic portals were established, and a diagnostic arthroscopy was performed. The intra-articular space of the shoulder had no signifiacnt pathology. Arthroscopic instruments were removed and the inserted into subacrominal space. The patient had a partial thickness tear of the rotator cuff and an abundant bursitis. The partial thickness tear of the rotator cuff was debrided and the bursitis was resected. The anterior acromion was clearly identified. The patient had an unstable os acromiale which was causing impingement. The os was determined to be small enough to be completely excised and the accessory ossicle was completely excised due to its small nature. The shoulder was then irrigated with a large amount of arthroscopic irrigant and injected with a solution of marcaine for post-op pain control. A pain pump was inserted for pos-operative pain contol as well. Incision was closed with interrupted nylon sutures.

    codes :29822,29826 and the excision of os acromiale?

    thank you
    Last edited by sblanchard; 09-30-2009 at 02:49 PM.

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