Shoulder surgery opinions please
I would like someone else to review this report for me please and see what you get for codes. I must confess to having difficulty with this physician and I'm not sure if I'm being "nitpicky" as he states or if I clearly don't understand what he's trying to say. I see where he exposed and excised the coracoacromial ligament and bursa, I see where the rotator cuff was identified, I see where the biceps tendon was repaired, I do not see where he mentions correcting the rotator cuff. He told me I was nitpicking and that it was very clear for any other surgeon to see. Maybe it's just my difficulties with this physician that makes it unclear to me? Would like your honest opinions please. If I'm wrong, I want to get myself back on track.
Preop Dx: rotator cuff tear, right shoulder, impingement syndrome with type 3 acromion and degenerative OA of acromioclavicular joint, right shoulder., 90% partial tear of the long head of the biceps tendon at the right shoulder.
Decompression acromioplasty resection of the coracoacromial ligament and subacromial bursectomy and removal of the osteophytes inferior to the acromioclavicular joint, right shoulder
Primary repair rotator cuff tendon utilizing arthrex corkscrew and swivelock repair of the rotator cuff, right shoulder
biceps tenodesis, right side.
Description of procedure: The patient was put in the supine position under general anesthesia with endotracheal intubation and then he was positioned in a beach chair position after prep and drape of the right shoulder and arm, using a 1-inch incision extending from the acromion over towards the coracoid, was made. The deltoid was opened along its fibers between the medial and lateral head. Type 3 acromion was exposed subperiosteally and this was excised, as well as the coracoacromial ligament and subacromial bursa.
After having this part of the surgery done, the rotator cuff was identified. It was torn not only longitudinally from the infraspinatus, but also it was totally detached from its footplate on the greater tuberosity. At this time, the joint was exposed and seen very easily. Irrigation was performed. The biceps was found to be only attached to the glenoid with only less than 10% of its width. The rest of it was shredded and partially torn right over the edge of the tuberosity and the tunnel. At this time, the biceps was detached from its glenoid attachment and, using a keyhole tenodesis, a tunnel was made inside the humerus and the tendon was rolled over itself and stuffed into the keyhole and locked in place with even elbow flexion and extension excellent fixation was achieved.
Irrigation was performed. The edges of the tendon were freshened up. The footplate of the humerus was cleaned out and prepared for the acceptance of the anchor sutures. The longitudinal part of the tear was repaired with non-absorbable ethibond and then placing three anchor sutures strategically, fiber wire sutures were passed through the tendon and the tendon was reduced over the tuberosity and was tightened. Using swivelock technique, a second row repair was perfomred on the side of the humerus. At the end repair was fantastic. The shoulder was taken to full range of motion with no evidence of impingement and no evidence of any disturbance at the area of the repair. Copious irrigation with bacitracin and irrigation solution was performed and, at this time, the wound was closed in layers with interrupted closure. There wer eno oprhopedic complications throuhout this procedure and he left the room in stable condition.
The codes the physician wants to code are: 23410, 23130, 23430
What I see is: 23430, 23130
Please see what anyone else can get? I am truly frustrated with this one.
Anna Weaver, CPC, CPMA, CEMC