Hey guys!!!

Just when I thought I was getting somewhat of better grip on shoulder coding - I get this one - any help will be greatly appreciated. Here is the opnote:

PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff arthropathy.

POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff arthropathy, labral tear/fraying, massive rotator cuf tear (supraspinatus and subscapularis), impingement syndrome/bursitis, chondromalacia

OPERATION PERFORMED: Right shoulder evaluation under anesthesia.
Right shoulder glenohumeral arthroscopy.
Debridement of labrum.
Partial synovectomy.
Debridement of full-thickness rotator cuff tear.
Subacromial decompression.
Greater tuberosity plasty.

INDICATIONS FOR PROCEDURE: The patient is a 77-year-old male who is right- hand dominant. Has been having right shoulder pain refractory to nonoperative management. X-rays and MRI revealed a chronic rotator cuff tear and some changes consistent with rotator cuff arthropathy. The
patient actually had excellent range of motion and had pain, and surgery
was indicated for pain purposes. He deferred any type of rotator cuff
tear, and given the appearance on the MRI this was actually a relative
contraindication given the chronicity and the atrophy and the fatty
infiltration as well as he deferred any kind of arthroplasty. He wanted
to try a more minimally invasive procedure for pain purposes. He
understood the limitations of surgery, understood the risks and benefits
as well. The patient signed a consent form, was medically deemed suitable
for surgery by is cardiologist and primary care doctor.

DESCRIPTION OF PROCEDURE: The patient was taken to the OR. The
shoulder was identified as the correct operative extremity by the patient.
This site was signed by the surgeon. One gram of vancomycin was given 90
minutes prior to incision. The patient was placed supine on the OR table.
After adequate general anesthesia was obtained, right shoulder was
examined under anesthesia, had full passive range of motion. There was
subacromial crepitus noted. The patient was then placed in the left
lateral decubitus position. All bony prominences were well padded.
Axillary roll was placed. The right shoulder was placed in 45 degrees
abduction, 20 degrees of forward elevation and with 10 pounds of traction.
The right shoulder was then prepped and draped in the standard surgical
fashion. A timeout was performed indicating a right shoulder arthroscopy
as the correct operative procedure. Local anesthesia was injected into
the subacromial space approximately 20 mL. A stab incision was made in
the posterior portal site. Arthroscope was inserted. There was noted to
be a significant amount of __________ chondromalacia as well as labral
fraying and a full-thickness rotator cuff tear. There was an absent
biceps tendon. The greater tuberosity was exposed. There was noted to be
massive tear involving the supraspinatus tendons. Using the anterior
superior portal made from the inside-out technique, a total debridement
was performed, a synovectomy was performed, debridement of the labrum was performed. Chondroplasty was performed with a 4.5 curved incisor as well as an ArthroCare wand. The subscapularis was noted to be partially torn in the upper aspect. There was no evidence of any Bankart lesion, no evidence of any loose bodies. Attention was directed to the subacromial
space. Using a direct lateral portal 3 cm off the anterior ledge of the
acromion a portal was made. A complete subacromial bursectomy was
performed. The coracoacromial ligament was left intact but just carefully
peeled off the anterior ledge of the acromion for exposure purposes for
the AC joint. Again, the rotator cuff was viewed from the bursal side and
again noted to be a full-thickness retracted tear to the glenoid. Again,
there was noted to be an absent biceps. Good hemostasis with the
ArthroCare wand. The remainder of the rotator cuff was debrided with a
4.5 curved incisor. The acromioplasty was performed with an acromionizer
making a type 2 acromion to a type 1. A greater tuberosity plasty was
performed as well taking the prominence of the greater tuberosity off the
surface of the anterior lateral aspect of it. The AC joint was not
addressed for the surgical procedure. The rotator cuff was grasped,
however, excursion was very limited, therefore the rotator cuff repair was
not even attempted at this time, and the patient understood this prior to