I have been trying to determine if this would truely need to be coded as an unlisted arthroscopic procedure (29999).


POSTOPERATIVE DIAGNOSIS: Refractory right subscapular bursitis.

Right arthroscopic subscapular bursectomy.

PROCEDURE IN DETAIL: The patient was taken to the operating room with both anesthesiologist and surgeons present. He was placed supine on the operating room table where general endotracheal anesthesia was induced without any problems or complications. He was then placed in a lateral decubitus position with his right shoulder above and all of his bony prominences were well padded and the beanbag was used and axillary roll was used as well. His right upper extremity was prepped in the usual sterile fashion, taken all the way to the midline and the mid aspect of the spine posteromedially; 30 cc of normal saline mixed with 10 cc of 0.5% Marcaine with epinephrine were injected into the subscapular bursa with the spinal needle. An incision was made just superior to the inferior portal of the scapula with the arm placed in a chicken-wing position and the scapula protracted opening up the scapular thoracic space. An incision was made and the subscapular bursa was swept using a blunt trocar. The arthroscope was placed and there was found to be extremely dense bursal tissue in the area. These were strands of scarred fibrous tissue that were very dense. An accessory portal was made approximately 3 cm superior to that just inferior to the scapular spine and a combination of a shaver and electrocautery was used to remove the bursa. This was done around the medial border of the scapula until the muscle fibers of the serratus anterior, inferior to ribcage were identified and scar tissue was completely resected all the way to the inferior angle and stopped at the scapular spine. A superior-angle resection was not performed as the patient did not have symptoms there preoperatively and his symptoms were localized to the middle aspect of the medial border of the scapula and bursa around there. Once we were satisfied that a complete bursectomy was performed and the muscle fibers were all identified, a spinal needle was placed into the subscapular space. All the instruments were then removed. The space was drained and 80 mg of Kenalog mixed with 20 cc of 0.5% Marcaine with epinephrine were injected into the subscapular space through a spinal needle and then those were removed. This was done after the skin was closed using 4-0 Monocryl subcuticular suture and the wound was dressed with Steri-Strips. The wound was then dressed with Xeroform followed by 4 x 4 gauze, ABD pad, and Medipore tape. The arm was placed in a sling. He was then extubated, transferred to the hospital gurney, and taken back to the recovery room in stable condition.