Below is the op note that I usually get from this physician.
Can you guys take a look at it and tell me how you would code it for Blue Shield? I keep thinking I am coding too much because I have too little.
Thank you so much!!! Denise
PREOPERATIVE DIAGNOSES: Right shoulder impingement syndrome, rotator
POSTOPERATIVE DIAGNOSES: Right shoulder impingement syndrome, rotator
cuff tear, plus type 1 labral tear.
PROCEDURES: Right shoulder arthroscopy, arthroscopic rotator cuff
repair, subacromial decompression, and labral debridement of type 1
INDICATIONS: The patient is a 55-year-old who has a long history of
right shoulder pain with weakness. Risks and benefits of surgery were
discussed with the patient and he wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating
room, placed supine on the operating room table. After induction of
an interscalene block, he was placed in the beach chair position. All
bony prominences were padded. His right shoulder was prepped and
draped in the standard surgical fashion. Posterior portal was
created. Examination of the joint showed normal glenohumeral
articular surfaces. The subscapularis was intact. Biceps tendon had
normal integrity. There was a type 1 labral tear, which was debrided
with a 3.5 mm full-radius shaver. There was a full thickness
supraspinatus tear. The greater tuberosity was exposed. Attention
was directed to the subacromial space where subacromial decompression
was carried out. A 6.5 Bio-Corkscrew anchor was placed into the
greater tuberosity and 2 horizontal mattress sutures were passed
through the tendon. The tendon was brought back nicely to the greater
tuberosity and tied down. This was confirmed going back
intraarticularly seeing the rotator cuff right at the articular
surface of the humeral head. The shoulder was irrigated. The portals
were closed with 4-0 Monocryl. Steri-Strips and dry sterile dressing
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