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  1. #1
    Default 29826?
    Medical Coding Books
    The patient was seen in the preoperative holding area. Surgical site was signed. Signed consent was verified, and the H&P updated and signed. The patient was given an interscalene block by anesthesia, which he tolerated well. He was then taken back to the operating room, and IV antibiotics were started. The patient was placed supine on the operating room table, and a general anesthetic was smoothly induced without complication.

    The patient was placed into the left lateral decubitus position. The right shoulder was sterilely prepped and draped in the usual fashion. The standard posterior approach to the shoulder was then made, and the scope was introduced into the glenohumeral joint. A quick inspection of the glenohumeral joint showed chondromalacia of the articular surface of the humeral head in the superior posterior aspect, an approximately 1 cm x 2 cm area of denuded cartilage, but not down to bone. This was felt to be grade 2, and possibly grade 3 at some of this level. The articular surface of the glenoid had some minor grade 2 changes as well. The glenoid labrum, anteriorly and posteriorly, was probed, and found to be intact. The patient was noted to have a Buford complex, which was stable, as was the biceps tendon attachment and exit. The rotator cuff reflexion appeared to be unremarkable, without evidence of tear. Minor fraying of the cuff at its posterior insertion area between the infra and supraspinatus area was noted.

    A shaving instrument was then introduced, which trimmed the chondromalacia from the head, as well as the glenoid surface. Some of the synovitis anteriorly was also shaved away. Electrocautery was used to smooth this out, as well as provide hemostasis. The rotator cuff intraarticular frayed area was also smoothed with electrocautery and a shaving instrument.

    The subacromial space was then entered. The bursitis overlying the anterior aspect of the joint was then removed. The extraarticular aspect of the cuff could be visualized completely, and found to have no evidence of tear. At the posterior margin of the cuff, where the supra and infraspinatus tendons met, there was an area of partial thickness tearing. This was again smoothed with a shaving instrument, and a cautery wand.

    The coracoacromial ligament was then released from the anterior aspect of the acromion, exposing an acromial hook, at least a type 2+. This was subsequently smoothed out and planed off about 5 to 7 mm in its inferior extent using a burr instrument. After this was planed and smoothed, adequate decompression was obtained. A bursectomy was also done for complete visualization of this area. The AC joint was checked and found to be relatively unremarkable, and left alone.

    The scope was concluded at that time. The patient tolerated the procedure well. Marcaine 0.25% with epinephrine was injected into all incision areas, and into the subacromial space. The patient was placed into a shoulder immobilizer and taken to the recovery room.

    DISPOSITION: The patient is to be re-evaluated in the office in seven days. Outpatient physical therapy has been instructed. Any problems, questions, or concerns, the patient is to return to see me sooner for re-evaluation. Sent home on Percocet for pain.

  2. #2
    29826-RT and 29822-59-RT. Send the Operative Report in with the claim.

  3. #3
    I have a question relating to the debridement (29822-29823). What is the documentation requirement for 29823 vs. 29822?

    The arthroscope was then bluntly introduced into the subacromial space and a mid lateral portal was established. Bursal hypertrophy was appreciated and using a 4.0 shaver a bursectomy was performed. There was some bursal surface fraying of the supraspinatus consistent with a partial tear involving less than 20% of the fibers. Using a 4.0 shaver debridement of the bursal surface tear was performed. A downsloping acromion was noted as well as a thickened coracoacromial ligament. Using the ArthroCare Wand, the coracoacromial ligament was released from its anterior-inferior insertion.

    Heather Stefani, CPC

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