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Thread: Shoulder surgery

  1. #1

    Default Shoulder surgery

    Promo: Code Books
    Hi everyone!!!

    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
    cuff tear.

    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
    labral tear.


    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
    was applied.

  2. #2
    Join Date
    Apr 2007
    Location
    Long Island/New York
    Posts
    1,273

    Default

    Quote Originally Posted by Desperate Denise View Post
    Hi everyone!!!

    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
    cuff tear.

    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
    labral tear.


    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
    was applied.
    29827 (RC repair), 29826 (Decompression) and 29822-59 (840.7). Usually I'd like to see better documentation for 29826 (bursectomy, work on acromion, etc.)

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